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Full text of "Medicare & you"

CENTERS FOR MEDICARE & MEDICAID SERVICES 



Medicare 




2009 




PUBS 
RA 
1412 
.3 

Y68 
2009 



This is the official government handbook with 
important information about the following: 

* What's new 

* 2009 Medicare costs 

* What Medicare covers 

' ' lealth and prescription drug plans 
our Medicare rights 
raud and identity theft 



^ 



SERVICE 







Welcome to Medicare & You 2009 

Medicare's goal is to make it easy for you to get the highest quality 
health care at the most affordable price. Medicare is transforming itself 
from a program which simply pays the bills to a program which actively 
supports a high quality health care system. 

What do we mean by a high quality health care system? It's a system 
that does the following: 

■ Rewards providers for quality and efficiency 

■ Uses objective standards to determine quality and efficiency 

■ Communicates using an interconnected, computerized health 
information network, so providers can get a comprehensive view of 
the patient securely and without delay 

■ Offers consumers complete, objective, easily accessible information, 
so they can make solid decisions about their own health care based on 
quality and price 

Medicare shares quality information about providers in your area at 
www.medicare.gov. 

In addition, this "Medicare & You" handbook is another way Medicare 
is working to make sure you have reliable information to help you make 
good health care decisions. 

Throughout this handbook, we have information about how you 
can get the most out of your Medicare, including Medicare health 
and prescription drug plan choices and coverage, how ta> protect 
yourself and Medicare from fraud, background on advance directives, 
and resources for detailed information and personalized help. This 
information is up-to-date between January 1, 2009-December 31, 2009. 
You will get a new handbook every fall to help you compare coverage 
and learn new and important information. 



Yours in good health, 



'o. 





Michael O. Leavitt 

Secretary 

Department of Health 
and Human Services 




tZL-d&rri^ 



Kerry N. Weems 

Acting Administrator 
Centers for Medicare & 
Medicaid Services 



■ 



! '.. 



-r^ 



■ 



Are You Getting the Most Out of Medicare? 

Use this checklist to find out. 

Ul Review how your current coverage will change and compare it 
to other coverage options for next year to see if there's a better 
choice for you. See page 44. 

Ll Remember that you can only join, switch, or drop Medicare 
plans at certain times. See pages 11, 59, and 65. 

Ql If you have other health insurance, find out how it works with 
Medicare. See pages 72-74. 

Q Call your State Health Insurance Assistance Program (SHIP) 
for free help with your Medicare questions. See pages 111-114 
for the telephone number. 

01 Ask your doctor or other health care provider which preventive 
services (like screenings, shots, and tests) you should get. Take 
the checklist on page 39 to your next visit. 

Ql Find out if you qualify for help paying your Medicare health 
and prescription drug costs. See pages 77-84. 

Ql Protect yourself from identity theft and fraud. See pages 94-97. 

Q Visit www.MyMedicare.gov to access your personalized 
Medicare information. Help save tax dollars by choosing to 
access future "Medicare & You" handbooks electronically. 

_J If you are new to Medicare, use the www.MyMedicare.gov 
password and instructions Medicare mailed to you. Fill out 
your Initial Enrollment Questionnaire (IEQ) online or the 
IEQ that was mailed to you, so Medicare can process your bills 
correctly. See page 109. If you have questions about the IEQ 
or to complete it over the telephone, call the Coordination of 
Benefits Contractor at 1-800-999-1118. TTY users should call 
1-800-318-8782. 

Ql If you are new to Medicare, get a one-time "Welcome to 

Medicare" physical exam. See "physical exam" on page 33 to see 
what's covered and what you pay. 



Important Information about 
This Handbook 

Please keep this handbook for future 

reference. Changes may occur after printing. 

Call 1-800-MEDICARE (1-800-633-4227), 

or visit www.medicare.gov to get the most 

current information. TTY users should call 

1-877-486-2048. 
This box lets 

J, Did your household get more than one copy of 

"Medicare & You?" If you would like to get only 
inthptpxt 

k lexi on£ in the future ^ caU i.goo-MEDICARE. 

are defined 

"Medicare & You" isn't a legal document. 
Official Medicare Program legal guidance is 
contained in the relevant statutes, regulations, 
and rulings. 

The term "Medicare health plan" is used 
throughout this handbook to include all 
Medicare Advantage Plans, Medicare Cost 
Plans, Demonstration/Pilot Programs, and 
Programs of All-inclusive Care for the Elderly 
(PACE). 



© 



This symbol highlights important information. 



are & You 2009 



7 Index — A Quick Way to Find What You Need 

11 Medicare Basics 

1 1 What's New and Important in 2009? 

12 What Is Medicare? 

14 Where to Get Your Medicare Questions Answered 

1 5 Section 1 —What's Covered? (Part A and Part B) 

19 Part A-Covered Services 

25 Part B-Covered Services 

38 What's NOT Covered by Part A and Part B? 

41 Section 2 — Decide How to Get Your Medicare 

42 Your Medicare Choices 

44 Things to Consider When Choosing or Changing Your Coverage 

45 Original Medicare 

50 Medicare Advantage Plans (like an HMO or PPO) (Part C) 

59 When Can You Join, Switch, or Drop a Medicare Advantage Plan? 

61 Other Medicare Health Plans 

63 Medicare Prescription Drug Coverage (Part D) 

65 When Can You Join, Switch, or Drop a Medicare Drug Plan? 

74 How Your Bills Get Paid If You Have Other Health Insurance 

75 Medigap (Medicare Supplement Insurance) Policies 

Continued ■=> 



What's new? 




^_ _ What's covered? 
I 5 What's not? 



41 




Coverage choices 




6 



Medicare& You 2009 



Contents 



(continued) 



77 Section 3 — Programs for People with Limited 
Income and Resources 

78 "Extra Help" Paying for Medicare Prescription Drug Coverage (Part D) 

82 Medicaid 

83 Medicare Savings Programs (Help from Medicaid to Pay Medicare 
Premiums) 

85 Section 4 — Protecting Yourself and Medicare 

86 Your Medicare Rights 

86 What Is an Appeal? 

92 How Medicare Uses Your Personal Information 

94 Protect Yourself from Fraud and Identity Theft 

96 Protect Yourself and Medicare from Billing Fraud 

99 Section 5 — Planning Ahead 

1 07 Section 6 — For More Information 
(Phone, Websites, Publications) 

115 Section 7 — Definitions 

119 2009 Medicare Costs 

124 Tips to Help Prevent Medicare Fraud 



Need "extra help" 
/O with costs? 




g^jm Fraud and 

94 identi ty the ft 

" 4 



11Q 2009 

" Medicare costs 








The page number in bold provides the most detailed information. 



Abdominal Aortic Aneurysm 26 

Acupuncture 38 

Advance Beneficiary Notice 89 

Advance Directives 105-106 

ALS (Amyotrophic Lateral Sclerosis) 17, 22 

Ambulance Services 26 

Ambulatory Surgical Center 26, 28, 38 

Appeal 52,86-91,108-109 

Artificial Limbs 34 

Assignment 25,46-47 

B 

Balance Exam 31 

Barium Enema 28 

Benefit Period 20,115,120 

Bills 46,74,89,96 

Blood 19,26,121 

Bone Mass Measurement (Bone Density) 27 

Braces (arm/leg/back/neck) 34 

Breast Exam 33,39 

C 

Cardiovascular Screenings 27, 39 

Catastrophic Coverage 67 

Chiropractic Services 27,38 

Claims 45-46,87,108-109 

Clinical Laboratory Services 27, 121 

Clinical Research Studies 20, 27 

COBRA 24,72 

Coinsurance 26-37, 45, 51, 66, 75, 78, 83, 115, 

120-121 
Colonoscopy 28,39 
Colorectal Cancer Screenings 28, 39 



C (continued) 

Community-Based Programs 103 
Consolidated Omnibus Budget Reconciliation Act 

(COBRA) 24,72 
Coordination of Benefits 14,74 
Copayment 51, 64, 66-67, 75, 78, 104, 115, 120-121 
Cosmetic Surgery 38 

Costs 16, 21, 25, 44, 53, 66-67, 75, 78, 119-122 
Coverage Choices 1 3, 41 -76 
Coverage Determination (Part D) 90-91 
Coverage Gap 66-67,78 
Covered Services (Part A and Part B) 1 9-20, 26-37, 39, 

120-121 
Creditable Prescription Drug Coverage 63, 65, 68, 

72-73,116 
Custodial Care 20,38,102,116 

D 

Deductible 25-37, 45, 51, 53, 55, 66, 75-76, 78, 83, 
116,117,120-121 

Definitions 115-118 

Demonstrations/Pilot Programs 13, 62, 94 

Dental Care and Dentures 38 

Department of Defense 14 

Department of Health and Human Services (Office of 

Inspector General) 14,95-97 
Department of Veterans Affairs 14, 68, 73 
Diabetes 29,30-32,39 

Dialysis (Kidney Dialysis) 12, 18, 32, 51, 54, 56, 58 
Discrimination 86,97 
Disenroll 52,56,60 
Drug Plan 43,63-71,90-91,122 
Drugs (outpatient) 34, 70 



8 



Index 



The page number in bold provides the most detailed information. 



D (continued) 

Drugs (prescription) 12, 34, 38, 44-45, 54-56, 63-71, 

117 
Durable Medical Equipment (like walkers) 19, 30-31, 

34,47,120-121 

E 

EKGs 35 

Eldercare Locator 103 

Electronic Handbook 122 

Electronic Health Record 101 

Emergency Room Services 30,108 

Employer Coverage 24, 43-45, 49, 57-58, 61, 64, 68, 

72,74,80 
End-Stage Renal Disease (ESRD) 12, 18, 22, 32, 51, 58 
Enroll 23,51,59-60,65,76 
Equipment (like walkers) 19, 30-31, 34, 47, 120-121 
Exception (Part D) 70, 90-91 
Extra Help (Help Paying Medicare Drug Costs) 63, 67, 

69,78-81 
Eye Exam 30,38 
Eyeglasses 30,38 

F 

Fecal Occult Blood Test 28,39 

Federal Employee Health Benefits Program 14, 73 

Federally-Qualified Health Center Services 30 

Flexible Sigmoidoscopy 28 

Flu Shot 30,39 

Foot Exam 31 

Formulary 44,70,78 

Fraud 94-97,124-125 

G 

Gap (Coverage) 66-67,78 

General Enrollment Period 18, 23 

Glaucoma Test 31,39 

Group Health Plan (Employer) 21, 23-24, 61, 74 



H 

Health Care Proxy 105-106 

Health Maintenance Organization (HMO) 43, 50, 54 

Hearing Aids 31,40 

Help with Costs 49,53,77-84 

Hepatitis B Shot 31,39 

Home Health Care 16,19,31,82,89,102,120 

Hospice Care 16,19,120 

Hospital Care (Inpatient Coverage) 16, 20, 30, 120 

I 

Identity Theft 94-95,97 
Immunizations 25,30-31,33,38-39 
Indian Health Service 73 
Institution 56,59,65,79,81,116 

J 

Join 

Medicare Drug Plan 45,49,63-65,68 
Medicare Health Plan 51,57-61 

K 

Kidney Dialysis 12,18,32,51,54,56,58 
Kidney Transplant 12,18,36,51,58 

L 

Late Enrollment Penalty 

Part A 18 

PartB 21,23 

PartD 68,122 
Lifetime Reserve Days 1 1 6, 1 20 
Limited Income 49, 53, 77-84, 108, 116 
Living Will 105-106 
Long-Term Care 20,38,62,82,102-104 
Low-Income Subsidy (LIS) 63, 67, 69, 78-81 

M 

Mammogram 32,39,54,56 

Medicaid 56,59,79,81,82,83 

Medical Equipment 19, 30-31, 34, 47, 120-121 



Index 



The page number in bold provides the most detailed information. 



M (continued) 

Medical Nutrition Therapy 32 

Medical Savings Account (MSA) Plans 55, 63 

Medically Necessary 21,30,116 

Medicare 

PartA 16-20,43,119-120 

PartB 21-37,39,43,119,121 

PartC 43,50-60,88,122 

PartD 43,63-71,90-91,122 
Medicare Advantage Plans 43, 50-60, 88, 122 
Medicare Authorization to Disclose Personal Health 

Information 108 
Medicare Beneficiary Ombudsman 98 
Medicare Card (lost) 17 
Medicare Cost Plan 61 
Medicare Prescription Drug Coverage 43, 49, 63-71, 

72-73,78-81,90-91 
Medicare Prescription Drug Plans (PDP) 43, 63-71, 

90-91,122 
Medicare Savings Programs 79, 83 
Medicare SELECT 57,75 

Medicare Summary Notice (MSN) 46, 77, 87, 92, 96-97 
Medigap (Medicare Supplement Insurance) 24, 43, 45, 

52,57,59,72,75-76 
Mental Health Care 20, 32, 110, 120-121 

N 

Nursing Home 56,81-82, 100, 102-104, 108, 110 
Nutrition Therapy Services 32 

O 

Occupational Therapy 19,31-32,121 

Office for Civil Rights 14,97 

Office of Inspector General 14,95-96 

Office of Personnel Management 14, 73 

Ombudsman (Medicare Beneficiary) 98 

Online 3,60,65,80,101,109 

Original Medicare 43, 45-49, 75-76, 87-89, 120-121 

Orthotic Items 34 



O (continued) 

Outpatient Hospital Services 28, 33, 121 
Oxygen 108 

P 

Pap Test 33,39,54,56 

PartA 16-20,43,119-120 
PartB 21-37,39,43,119,121 
PartC 43,50-60,88,122 
PartD 43,63-71,90-91,122 
Payment Options (premium) 71,119 
Pelvic Exam 33,39,54,56 
Penalty 

PartA 18 

PartB 21,23 

PartD 68,122 
Personal Health Record 101 
Physical Exam 26,30,33,38-39 
Physical Therapy 19-20,31-33,118,121 
Pilot/Demonstration Programs 62, 94 
Pneumococcal Shot 33 
Power of Attorney 105 
Practitioner Services 34 
Preferred Provider Organization (PP0) Plan 54 
Premium 16-17,21,53,66,68,71,78,83,117,119 
Prescription Drugs 34, 38, 44-45, 54-56, 63-71, 

72-73,78-79,82,103 
Preventive Services 25-34, 39, 108-110 
Primary Care Doctor 45, 54-56, 117 
Privacy Notice 92-93 
Private Contract 48 

Private Fee-for-Service (PFFS) Plans 55, 63, 1 1 
Private Insurance 61,72,75-76,102 
Programs of All-Inclusive Care for the Elderly (PACE) 62, 

82,103-104 
Prostate Screening (PSA Test) 34, 39 
Proxy (Health Care) 105-106 
Publications 110 



10 



Index 



The page number in bold provides the most detailed information. 



Quality of Care 14,44,88,100,109-110 
Quality Improvement Organization (QI0) 14, 88, 99, 
113 

R 

Railroad Retirement Board (RRB) 14, 17-18, 22-23, 

46, 124 
Referral 26, 33, 44-45, 51-52, 54-56, 1 1 7 
Religious Nonmedical Health Care Institution 16 
Replacing a Medicare Card 17 
Retiree Health Insurance 24, 43-45, 49, 57-58, 61, 64, 

68,72,74 
Rural Health Clinic 34 

S 

Second Surgical Opinions 34 

Service Area 44,51,59,64-65,117 

Shots (vaccinations) 25, 30-31, 33, 38-39 

Sigmoidoscopy 28,39 

Skilled Nursing Facility (SNF) Care 16, 20, 88, 102, 110, 

118 
Smoking Cessation 34,39 
SMP (Senior Medicare Patrol) Program 95 
Social Security 14, 17-18, 21-23, 71, 80-81, 84 
Special Enrollment Period 18, 23-24, 65, 72 
Special Needs Plan (SNP) 56,58 
Speech-language Pathology 19, 31, 35, 121 
State Health Insurance Assistance Program (SHIP) 14, 

111-114 
State Medical Assistance (Medicaid) Office 53, 62, 80, 

82-83,104 
State Pharmacy Assistance Program (SPAP) 82 
Substance Abuse 32 
Supplemental Policy (see Medigap) 24, 43, 45, 52, 57, 

59,72,75-76 
Supplemental Security Income (SSI) 79, 84 
Supplies (medical) 19-20, 25, 29-34, 46-47, 96, 108 
Surgical Dressing Services 35 



Telemedicine 35 

Tests 26-29,31-35,38-39,101 

Tiers (drug formulary) 70 

Transplant Services 36 

Travel 37 

TRICARE 14,24,68,73 

TTY 14,118 

U 

Union 24, 43-45, 49, 57-58, 61, 64, 68, 72, 74, 80 
Urgently Needed Care 37,51,54,56 

V 

Vaccinations (shots) 25, 30-31, 33, 39-40 
Veterans Benefits (VA) 14,68,73 
Vision 51 

W 

Walkers 30,108 

Website 63,70,100,107 

Welcome to Medicare Physical Exam 26, 30, 33, 39 

Wheelchairs 30,108 

www.medicare.gov 100,109 

www.MyMedicare.gov 39, 46, 87, 109 

X 

X-ray 35 



m 





What's New and Important in 2009? 

■ One-Time "Welcome to Medicare" physical exam — More time 
and lower cost. See page 33. 

■ Fraud and Identity Theft — Protect yourself and Medicare. See 
pages 94-97. 

■ Planning Ahead — Plan for your current and future health care 
needs. See pages 99-106. 

■ New Technology — Electronic and Personal Health Records. See 
page 101. 

■ Medicare health and prescription drug plans— Visit 
www.medicare.gov or call 1-800-MEDICARE (1-800-633-4227) to 
find plans in your area. TTY users should call 1-877-486-2048. 

■ What You Pay for Medicare (Part A and Part B) — The amounts 
you will pay in 2009 are on pages 119-121. 

■ Electronic Handbook — Choose to get future "Medicare & You" 
handbooks electronically. See page 122. 

Plan Coverage and Costs Change Yearly. 

Mark your calendar with these important dates! 

October 2008: Prepare and Compare 

Your health, finances, or coverage may have changed in the last year. 
Look at the cost, coverage, quality, and convenience your current 
Medicare health or prescription drug coverage will offer in 2009, and 
compare it with other available coverage options to see if there's a 
better choice for you. 

November 1 5, 2008-December 31 , 2008: Stay or Switch 

You can switch your Medicare health or prescription drug coverage 
for 2009 during this period. 

January 1, 2009: 2009 Coverage and Costs Begin 

New coverage begins if you made a change between 

November 15, 2008-December 31, 2008. New costs and coverage 

changes also begin if you keep your current coverage. 

Note: There may be other times when you can change your Medicare 
health or prescription drug coverage. See pages 59 and 65. 



12 



Medicare Basics 



What Is Medicare? 

Medicare is health insurance for people age 65 or older, under age 65 with 
certain disabilities, and any age with End-Stage Renal Disease (ESRD) 
(permanent kidney failure requiring dialysis or a kidney transplant). 

The Different Parts of Medicare 

The different parts of Medicare help cover specific services if you meet 
certain conditions. Medicare has the following parts: 



Medicare Part A (Hospital Insurance) 



■ Helps cover inpatient care in hospitals 

■ Helps cover skilled nursing facility, hospice, and home health care 

See pages 16-20. 



Medicare Part B (Medical Insurance) 



■ Helps cover doctors' services and outpatient care 

■ Helps cover some preventive services to help maintain your health 
and to keep certain illnesses from getting worse 

See pages 21-37. 



Medicare Part C (Medicare Advantage Plans) (like an HMO or PPO) 



■ A health coverage choice run by private companies approved by 
Medicare 

■ Includes Part A, Part B, and usually other coverage including 
prescription drugs 

See the next page. 



Medicare Part D (Prescription Drug Coverage) 



■ Helps cover the cost of prescription drugs 

■ May help lower your prescription drug costs and help protect against 
higher costs in the future 

Seepages 63-71. 



Medicare Basics 13 

Your Medicare Coverage Choices 

With Medicare, you can choose how you get your health and prescription drug 
coverage. Below are brief descriptions of your coverage choices. Section 2 has 
more details about these choices and information to help you decide. 

Original Medicare (See pages 45-49.) 

■ Run by the Federal government. 

■ Provides your Part A and Part B coverage. 

■ You can join a Medicare Prescription Drug Plan to add drug coverage. 

■ You can buy a Medigap (Medicare Supplement Insurance) policy (sold 
by private insurance companies) to help fill the gaps in Part A and Part B 
coverage. See pages 75-76. 

Medicare Advantage Plans (like an HMO or PPO) (See pages 50-60.) 

■ Run by private companies approved by Medicare. 

■ Provides your Part A and Part B coverage but can charge different amounts 
for certain services. May offer extra coverage and prescription drug 
coverage for an extra cost. Costs for items and services vary by plan. 

■ If you want drug coverage, you must get it through your plan (in most cases). 

■ You don't need a Medigap policy. 

Other Medicare Health Plans (See pages 61-62 and 103-104.) 

■ Plans that aren't Medicare Advantage Plans, but are still part of Medicare. 

■ Include Medicare Cost Plans, Demonstration/Pilot Programs, and 
Programs of All-inclusive Care for the Elderly (PACE). 

■ Some plans provide Part A and Part B coverage, and some also provide 
prescription drug coverage (Part D). 

Note: You might also have health and/or prescription drug coverage from a 
former or current employer or union. See pages 72-73. 

See page 43 for a chart that explains your Medicare coverage choices 
and the decisions you need to make. 



14 



Medicare Basics 



Where to Get Your Medicare Questions Answered 



1-800-MEDICARE 

To get general Medicare information. See page 108. 


1-800-633-4227 
TTY 1-877-486-2048 


State Health Insurance Assistance Program (SHIP) 

To get free personalized health insurance counseling, 
including help making health care decisions, information on 
programs for people with limited income and resources, and 
help with claims, billing, and appeals. 


Seepages 111-114. 


Social Security 

To get a replacement Medicare card, change your address or 
name, get information about Part A and/or Part B eligibility, 
entitlement, and enrollment, apply for "extra help" with 
Medicare prescription drug costs, and report a death. 


1-800-772-1213 
TTY 1-800-325-0778 


Coordination of Benefits Contractor 

To get information on whether Medicare or your other 
insurance pays first. 


1-800-999-1118 
TTY 1-800-318-8782 


Department of Defense 

To get information about TRICARE. 

To get information about TRICARE for Life. 


1-888-363-5433 
1-866-773-0404 
TTY 1-866-773-0405 


Department of Health and Human Services 
Office of Inspector General 

If you suspect fraud, see pages 94-97. 
Office for Civil Rights 

If you think you've been treated unfairly, see page 97. 


1-800-447-8477 
TTY 1-800-377-4950 
1-800-368-1019 
TTY 1-800-537-7697 


Department of Veterans Affairs 

If you are a veteran or have served in the U.S. military. 


1-800-827-1000 
TTY 1-800-829-4833 


Office of Personnel Management 

To get information about the Federal Employee Health 
Benefits Program for current and retired Federal employees. 


1-888-767-6738 
TTY 1-800-878-5707 


Railroad Retirement Board (RRB) 

If you have benefits from the RRB, call them to change your 
address or name, enroll in Medicare, replace your Medicare 
card, and report a death. 


Local RRB office or 
1-800-808-0772 
After January 1,2009, 
call 1-877-772-5772. 


Quality Improvement Organization (QIO) 

To ask questions or report complaints about the quality of 
care for a Medicare- covered service. 


1-800-MEDICARE 

to get the telephone 
number for your QIO. 



SECTION 1 ' r 





Medicare is here to help you stay healthy. We're committed 
to providing you with information that can help you 
make informed health care decisions. This section explains what 
Medicare covers. 

Section 1 includes information about the following: 

Medicare Part A (Hospital Insurance) and What It Covers . . 16-20 
Medicare Part B (Medical Insurance) and What It Covers . . 21-37 

What's NOT Covered by Part A and Part B? 38 

Preventive Services Checklist 39 



16 



Section 1— What's Covered? (Part A and Part B) 




Blue words 
in the text 
are defined 
on pages 
115-118. 



What Services Does Medicare Cover? 

Medicare covers certain medical services and supplies in hospitals, 
doctors' offices, and other health care settings. Services are either 
covered under Medicare Part A (Hospital Insurance) or Medicare 
Part B (Medical Insurance). If you have both Part A and Part B, 
you can get the full range of Medicare-covered services listed here, 
no matter what type of Medicare coverage you choose. 

A list of the services covered by Part A is on pages 19-20. 
A list of the services covered by Part B is on pages 26-37. 

What Is Part A (Hospital Insurance)? 

Part A helps cover the following: 

■ Inpatient care in hospitals (includes critical access hospitals and 
inpatient rehabilitation facilities) 

■ Inpatient stays in a skilled nursing facility (not custodial or 
long-term care) 

■ Hospice care services 

■ Home health care services 

■ Inpatient care in a Religious Nonmedical Health Care Institution 
(facility that provides non-medical, non-religious health care 
items and services to people who need hospital or skilled 
nursing facility care but for whom that care wouldn't be in 
agreement with their religious beliefs) 

See pages 17-18 for the conditions you must meet to get 
Part A-covered services. 

You usually don't pay a monthly premium for Part A coverage if 
you or your spouse paid Medicare taxes while working. 

If you aren't eligible for premium-free Part A, you may be able to 
buy Part A if you meet the citizenship or residency requirements 
and you are age 65 or older or you are under age 65, disabled, and 
your premium-free Part A coverage ended because you returned 
to work. 

Note: The 2009 premium amount for people who buy Part A is up 
to $443 each month. 



Section 1— What's Covered? (Part A and Part B) 



17 



What Is Part A (Hospital Insurance)? (continued) 

In most cases, if you choose to buy Part A, you must also have Part B 
and pay monthly premiums for both. 

If you have limited income and resources, your state may help you pay 
for Part A and/or Part B. See page 83. 

You can find out if you have Part A by looking at your Medicare card. 

Note: Keep this card safe. If you have 
Original Medicare, you will use this 
card to get your Medicare -covered 
services. If you join a Medicare plan, 
you must use the card from the plan to 
get your Medicare-covered services. 




1-800-MEDICARE (1-800-633-4227) 

NAME OF BENEFICIARY 

JANE DOE 

MEDICARE CLAIM NUMBER SEX 

000-00-0000-A FEMALI 

IS ENTITLED TO EFFECTIVE DATE 






HOSPITAL 
MEDICAL 



(PART A) 
(PART B) 



07-01-1986 
07-01-1986 



SIGN 
HERE 






""** \fajvjis tAJog/ 



See pages 94-97 to find out about 
protecting yourself from identity theft 
and fraud. 



Is Your Medicare Card Lost or Damaged? 

To order a new card, call Social Security at 1-800-772-1213, or visit 
www.socialsecurity.gov. TTY users should call 1-800-325-0778. If 
you get benefits from the RRB, visit www.rrb.gov and select, "Benefit 
Online Services," or call your local RRB office. After January 1, 2009, 
call the RRB toll-free at 1-877-772-5772. 




When Can You Sign Up for Part A? 

Many People Automatically Get Part A 

If you get benefits from Social Security or the RRB, you automatically 
get Part A starting the first day of the month you turn age 65. If you 
are under age 65 and disabled, you automatically get Part A after you 
get disability benefits from Social Security or certain disability benefits 
from the RRB for 24 months. You will get your Medicare card in 
the mail 3 months before your 65th birthday or your 25th month of 
disability. 

If you have ALS (Amyotrophic Lateral Sclerosis, also called 

Lou Gehrig's disease), you automatically get Part A the month your 

disability benefits begin. 



18 



Section 1— What's Covered? (Part A and Part B) 





Blue words 
in the text 
are defined 
on pages 
115-118. 



When Can You Sign Up for Part A? (continued) 

Some People Need to Sign up for Part A 

If you aren't getting Social Security or RRB benefits (for instance, 
because you are still working), you will need to sign up for Part A. 
You will need to sign up even if you are eligible for premium-free 
Part A. You should contact Social Security 3 months before you 
turn age 65. If you worked for a railroad, contact the RRB to sign up. 

If you have End- Stage Renal Disease (ESRD), you can 
sign up for Part A by visiting your local Social Security 
office or by calling Social Security at 1-800-772-1213. 
TTY users should call 1-800-325-0778. To get more 
information on how to enroll in Medicare if you have 
ESRD, visit 

www.medicare.gov/Publications/Pubs/pdf/10128.pdf 
to view the booklet, "Medicare Coverage of Kidney 
Dialysis and Kidney Transplant Services." 

If you aren't eligible for premium-free Part A, you can buy it 
during the following times: 

■ Initial Enrollment Period — When you first become eligible for 
Medicare (3 months before you turn age 65 to 3 months after the 
month you turn age 65). 

■ General Enrollment Period — Between January 1 -March 31 each 
year. 

■ Special Enrollment Period — If you or your spouse (or family 
member if you are disabled) is working and has group health plan 
coverage through the employer or union. See page 23. 

■ Special Enrollment Period for International Volunteers — If you 
are serving as a volunteer in a foreign country. See page 23. 

If you don't buy Part A when you are first eligible, the monthly 
premium may go up 10% unless you are eligible for a special 
enrollment period. 

For more information on Part A, call Social Security, or visit 
www.socialsecurity.gov If you get benefits from the RRB, call your 
local RRB office or 1-800-808-0772. After January 1, 2009, call the 
RRB toll-free at 1-877-772-5772. 



Section 1 —What's Covered? (Part A and Part B) 



Part A-Covered Services 



Biood 


If the hospital has to buy blood for you, you must either pay the 
hospital costs for the first 3 pints of blood you get in a calendar 
year or have the blood donated. In most cases, the hospital gets 
blood from a blood bank at no charge, and you won't have to pay 
for it or replace it. 


Home 
Health 
Services 


Limited to medically- necessary part-time or intermittent skilled 
nursing care or physical therapy, speech-language pathology, or a 
continuing need for occupational therapy. Care must be ordered 
by a doctor and provided by a Medicare-certified home health 
agency. Home health services may also include medical social 
services, part-time or intermittent home health aide services, 
durable medical equipment (see page 30), and medical supplies 
for use at home. You must be homebound, which means that 
leaving home takes a lot of effort. Part A covers the cost of the 
first 100 home health visits following a hospital stay. 


Hospice 
Care 


For people with a terminal illness who are expected to live 6 
months or less (as certified by a doctor). Coverage may include 
drugs (for pain relief and symptom management), medical, 
nursing, social services, and other covered services as well as 
services not usually covered by Medicare (like grief counseling). 
Hospice care is usually given in your home (or other facility like 
a nursing home) by a Medicare- approved hospice. Medicare 
covers some short-term inpatient stays (for pain and symptom 
management that requires an inpatient stay) in a Medicare- 
approved facility, such as a hospice facility, hospital, or skilled 
nursing facility. Medicare also covers inpatient respite care (care 
given to a hospice patient so that the usual caregiver can rest). 
You can stay in a Medicare- approved facility up to 5 days each 
time you get respite care. Medicare may pay for covered services 
for health problems that aren't related to your terminal illness. 
You can continue to get hospice care as long as the hospice 
medical director or hospice doctor recertifies that you are 
terminally ill. 



See page 120 for specific costs and other information about these services. 



20 



Section 1— What's Covered? (Part A and Part B) 



Part A-Covered Services 



Hospital 

Stays 

(Inpatient) 



Includes semi-private room, meals, general nursing, drugs as 
part of your inpatient treatment, and other hospital services and 
supplies. Examples include inpatient care you get in acute care 
hospitals, critical access hospitals, inpatient rehabilitation facilities, 
long-term care hospitals, inpatient care as part of a qualifying 
clinical research study (see page 27), and mental health care. This 
doesn't include private- duty nursing, a television or telephone in 
your room, or personal care items like razors or slipper socks. It 
also doesn't include a private room, unless medically necessary. 
The doctor services you get while you are in a hospital are covered 
under Part B. See page 30. For emergency room services, also see 
page 30. 



Skilled 
Nursing 
Facility 
Care 



Includes semi-private room, meals, skilled nursing and 
rehabilitative services, and other services and supplies (only after 
a 3 -day minimum inpatient hospital stay for a related illness or 
injury) for up to 100 days in a benefit period. To get care in a 
skilled nursing facility, your doctor must certify that you need 
daily skilled care like intravenous injections or physical therapy. 
Medicare doesn't cover long-term care or custodial care in this 
setting. See pages 102-104. 



See page 120 for specific costs and other information about these services. 



Section 1— What's Covered? (Part A and Part B) 



What Is Part B (Medical Insurance)? 

Part B helps cover medically-necessary services like doctors' services, 
outpatient care, and other medical services. Part B also covers some 
preventive services. You can find out if you have Part B by looking at 
your Medicare card. See the sample card on page 17. 

How Much Does Part B Cost? 

You pay the Part B premium each month. Most people will pay 
the standard premium amount, which is $96.40 in 2009. However, 
your monthly premium will be higher if you meet the following 
conditions: 

■ You are single (file an individual tax return), and your yearly 
modified adjusted gross income is more than $85,000 (in 2009). 

■ You are married (file a joint tax return), and your yearly modified 
adjusted gross income is more than $170,000 (in 2009). 

The 2009 Part B premium amounts are on page 119. 

Your modified adjusted gross income is your adjusted gross (taxable) 

income plus your tax exempt interest income. Social Security will 

notify you if you have to pay more than the standard premium. If 

you have to pay a higher amount for your Part B premium and you 

disagree, call Social Security. 

Blue words 

. ., . . If you have limited income and resources, see page 83 for 

in the text ' , 

. r ■ information about help paying your Medicare premiums. 

on pages You also pay a Part B deductible each year before Medicare starts to 

115-118. pay its share. In 2009, the deductible amount is $135. 

What Is the Part B Late Enrollment Penalty? 

If you don't sign up for Part B when you are first eligible, your 
monthly premium for Part B may go up 10% for each full 12-month 
period that you could have had Part B, but didn't sign up for it. If 
you delay taking Part B because you or your spouse (or a family 
member, if you are disabled) is working and has group health plan 
coverage based on current employment, you may not have to pay the 
higher premium. See page 23 ("Special Enrollment Period") for more 
information. 



21 



22 




Section 1— What's Covered? (Part A and Part B) 



When Can You Sign Up for Part B? 

If you get benefits from Social Security or the RRB, you will 
automatically get Part B starting the first day of the month you turn 
age 65. If you are under age 65 and disabled, you will automatically 
get Part B after you get disability benefits from Social Security or 
certain disability benefits from the RRB for 24 months. You will get 
your Medicare card in the mail about 3 months before your 65th 
birthday or your 25th month of disability. If you don't want Part B, 
follow the instructions that come with the card, and send the card 
back. If you keep the card, you keep Part B and will pay Part B 
premiums. 

If you have ALS (Amyotrophic Lateral Sclerosis, also called 

Lou Gehrig's disease), you automatically get Part B the month your 

disability benefits begin. 

If you have ESRD, you can sign up for Part B when you sign up for 
Part A. (See page 18 to find out how to get more information.) 

If you aren't getting Social Security or RRB benefits, and you want 
to get Part B, you will need to sign up for Part B during your initial 
enrollment period (the period that begins 3 months before the 
month of your 65th birthday and ends 3 months after the month of 
your 65th birthday). 



Section 1— What's Covered? (Part A and Part B) 



23 




Blue words 
in the text 
are defined 
on pages 
115-118. 






When Can You Sign Up for Part B? (continued) 

If you didn't sign up for Part B when you first became eligible, you 
may be able to sign up during one of these times: 

■ General Enrollment Period — Between January 1 -March 31 each 
year. Your coverage will begin on July 1. The cost of your Part B will 
go up 10% for each full 12-month period you could have had Part B 
but didn't sign up for it, unless you qualify for a special enrollment 
period (see below). You may have to pay this late enrollment 
penalty as long as you have Part B. 

■ Special Enrollment Period — If you wait to sign up for Part B 
because you or your spouse is working and has group health plan 
coverage based on that work, or if you are disabled and you or a 
family member is working and has group health plan coverage based 
on that work. You can sign up for Part B any time while you have 
group health plan coverage based on current employment or during 
the 8-month period that begins the month the employment ends, or 
the group health plan coverage ends, whichever happens first. 

■ Special Enrollment Period for International Volunteers — If 
you waited to enroll in Part B because you had health insurance 
while volunteering in a foreign country. You can sign up during 
the 6-month period that begins the month you are no longer 
volunteering outside the United States, or the sponsoring 
organization is no longer tax exempt, or you no longer have health 
coverage outside the U.S., whichever comes first. 

Usually, you don't pay a late enrollment penalty if you sign up for 
Part B during a special enrollment period. 

Call Social Security at 1-800-772-1213 for more information 
about your Medicare eligibility and to enroll in Part B. TTY users 
should call 1-800-325-0778. If you get RRB benefits, call your local 
RRB office or 1-800-808-0772. After January 1, 2009, call the RRB 
toll-free at 1-877-772-5772. For general information about enrolling, 
visit www.medicare.gov and select, "Find Out if You Are Eligible 
for Medicare and When You Can Enroll." You can also get free 
personalized health insurance counseling from your State Health 
Insurance Assistance Program (SHIP). See pages 1 1 1-1 14 for the 
telephone number. 



24 Section 1 —What's Covered? (Part A and Part B) 

Part B and TRICARE Coverage 

If you have Medicare and you also have TRICARE coverage (for 
active-duty military or retirees and their families), you will need 
to contact TRICARE to find out what you need to do if you want 
to keep TRICARE. For example, you may have to buy Part B if 
you or your spouse is no longer active duty. 

See page 73 for more information about TRICARE. 

Note: If you are in a Medicare Advantage Plan or choose to join a 
plan, tell the plan you have TRICARE. 

Part B and Group Health Plan Coverage from 
an Employer or Union 

Your Part B enrollment rights can be affected if you have coverage 
through an employer (including FEHBP) or union, and you or 
your spouse is still working. 

When the employment ends, three things happen: 

1. You may get a chance to elect COBRA coverage, which 
continues your health coverage through the employer s plan 
(in most cases for only 18 months) and probably at a higher 
cost to you. 

2. You may get a special enrollment period to sign up for Part B 
without a penalty. This period only lasts for 8 months after 
your employment ends. This period will run whether or not 
you elect COBRA, so if you wait until your COBRA ends, your 
special enrollment period will probably be over. 

3. If you sign up for Part B, it will also start a 6-month Medigap 
open enrollment period which gives you a guaranteed right to 
buy a Medigap (Medicare Supplement Insurance) policy. Once 
this period starts, it also can't be delayed or repeated. See 
pages 75-76. 



Section 1— What's Covered? (Part A and Part B) 



25 




j 




Blue words 
in the text 
are defined 
on pages 
115-118. 



O 



Part B-Covered Services 

Medically-necessary services — Services or supplies that are needed 
for the diagnosis or treatment of your medical condition and meet 
accepted standards of medical practice. 

Preventive services— Health care to prevent illness or detect illness 
at an early stage, when treatment is most likely to work best (for 
example, Pap tests, flu shots, and prostate cancer screenings). 

Pages 26-37 include an alphabetical list of common services covered 
by Medicare Part B. To find out if Medicare covers a service that's 
not included on this list, visit www.medicare.gov and select, "Find 
Out What Medicare Covers." You can also call 1-800-MEDICARE 
(1-800-633-4227). TTY users should call 1-877-486-2048. 

You will see this symbol next to preventive services. 

Your doctor or other health care provider can help you better 
understand the preventive services Medicare covers and will tell you 
which services you need. 

What You Pay for Medicare Part B-Covered 
Services 

Costs for Part B services vary depending on whether you have 
Original Medicare or are in a Medicare health plan. The charts on 
pages 26-38 give general information about what you must pay 
if you have Original Medicare. You generally have to pay for the 
doctors visit, even if there is no cost for the service itself. If the 
Part B deductible applies, you must pay all costs until you meet the 
yearly Part B deductible before Medicare begins to pay its share. See 
page 121 for the Part B deductible amount. Then, you typically pay 
20% of the Medicare- approved amount of the service. You can save 
money if you choose doctors or providers who accept assignment. 
See page 47. You also may be able to save money on your Medicare 
costs if you have limited income and resources. See pages 82-84. 

If you join a Medicare Advantage Plan (like an HMO or PPO) 
or have other insurance (like a Medigap policy, or employer or 
union coverage), your costs may be different from those shown 
on pages 26-37. For more information about the different costs, 
contact the plans you are interested in. 



26 



Section 1— What's Covered? (Part A and Part B) 



» 



Part B-Covered Services 



Abdominal 
Aortic 
Aneurysm 
Screening 


A one-time screening ultrasound for people at risk. Medicare 
only covers this screening if you get a referral for it as a 
result of your one-time "Welcome to Medicare" physical 
exam. See "physical exam" on page 33. You pay 20% of the 
Medicare-approved amount. 


Ambulance 
Services 


Emergency ground transportation when you need to be 
transported to a hospital or skilled nursing facility for 
medically-necessary services, and transportation in any 
other vehicle could endanger your health. Medicare will pay 
for transportation in an airplane or helicopter if you require 
immediate and rapid ambulance transportation that ground 
transportation can't provide. 

In some cases, Medicare may pay for limited non-emergency 
transportation if you have orders from your doctor. Medicare 
will only cover services to the nearest appropriate medical 
facility that is able to give you the care you need. You pay 20% 
of the Medicare-approved amount, and the Part B deductible 
applies. 


Ambulatory 

Surgical 

Centers 


Facility fees for approved surgical procedures provided in an 
ambulatory surgical center (facility where surgical procedures 
are performed, and the patient is released the same day). You 
pay 20% of the Medicare -approved amount (except for flexible 
sigmoidoscopies and screening colonoscopies, for which you 
pay 25%), and the Part B deductible applies. You pay all facility 
charges for procedures Medicare doesn't allow in ambulatory 
surgical centers. 


Blood 


If the provider has to buy blood for you, you must either pay the 
provider costs for the first 3 pints of blood you get in a calendar 
year or have the blood donated. In most cases, the provider gets 
blood from a blood bank at no charge, and you won't have to 
pay for it or replace it. You pay 20% of the Medicare-approved 
amount for additional pints of blood you get as an outpatient, 
and the Part B deductible applies. 



Part B deductible and coinsurance amounts are on page 121. 



Section 1— What's Covered? (Part A and Part B) 



27 






Part B-Covered Services 



Bone Mass 
Measurement 
(Bone Density) 


Helps to see if you are at risk for broken bones. This service 
is covered once every 24 months (more often if medically 
necessary) for people who have certain medical conditions 
or meet certain criteria. You pay 20% of the Medicare- 
approved amount, and the Part B deductible applies. 


Cardiovascular 
Screenings 


Helps prevent a heart attack or stroke. This service is 
covered every 5 years to test your cholesterol, lipid, and 
triglyceride levels. No cost for the test, but you generally 
have to pay 20% of the Medicare-approved amount for the 
doctor s visit. 


Chiropractic 
Services (limited) 


Helps correct a subluxation (when one or more of the bones 
of your spine move out of position) using manipulation of 
the spine. You pay 20% of the Medicare-approved amount, 
and the Part B deductible applies. 


Clinical Laboratory 
Services 


Including certain blood tests, urinalysis, some screening 
tests, and more. No cost to you. 


Clinical Research 
Studies 


Clinical research studies test different types of medical 
care, like how well a cancer drug works. Medicare covers 
some costs, like doctor visits and tests, in qualifying clinical 
research studies. Clinical research studies help doctors and 
researchers see if the new care works and if it's safe. You 
pay 20% of the Medicare-approved amount, and the Part B 
deductible applies. 



Part B deductible and coinsurance amounts are on page 121. 



28 



Section 1— What's Covered? (Part A and Part B) 



v 



Part B-Covered Services 



Colorectal 

Cancer 

Screenings 


To help find precancerous growths and help prevent or find 
cancer early, when treatment is most effective. One or more of 
the following tests may be covered. Talk to your doctor. 

■ Fecal Occult Blood Test — Once every 12 months if age 50 or 
older. No cost for the test, but generally you have to pay 20% of 
the Medicare-approved amount for the doctor's visit. 

■ Flexible Sigmoidoscopy — Generally, once every 48 months 
if age 50 or older, or for those not at high risk, 120 months 
after a previous screening colonoscopy. You pay 20% of the 
Medicare -approved amount. 

■ Colonoscopy — Generally once every 120 months (high risk 
every 24 months) or 48 months after a previous flexible 
sigmoidoscopy. No minimum age. You pay 20% of the 
Medicare-approved amount. 

■ Barium Enema — Once every 48 months if age 50 or older (high 
risk every 24 months) when used instead of a sigmoidoscopy or 
colonoscopy. You pay 20% of the Medicare-approved amount. 

Note: If you get a flexible sigmoidoscopy or screening 
colonoscopy in an outpatient hospital setting or an ambulatory 
surgical center, you pay 25% of the Medicare-approved amount. 


Defibrillator 

(Implantable 

Automatic) 


For some people diagnosed with heart failure. You pay 20% of 
the Medicare-approved amount, but no more than the Part A 
hospital stay deductible (see page 120) if you get the device as a 
hospital outpatient. The Part B deductible applies. 



Part B deductible and coinsurance amounts are on page 121, 



Section 1 —What's Covered? (Part A and Part B) 



29 



j 



Part B-Covered Services 



* 



Diabetes 
Screenings 



Checks for diabetes. These screenings are covered if you 
have any of the following risk factors: high blood pressure 
(hypertension), history of abnormal cholesterol and 
triglyceride levels (dyslipidemia), obesity, or a history of high 
blood sugar (glucose). Tests are also covered if you answer 
yes to two or more of the following questions: 

■ Are you age 65 or older? 

■ Are you overweight? 

■ Do you have a family history of diabetes (parents, siblings)? 

■ Do you have a history of gestational diabetes (diabetes 
during pregnancy), or did you deliver a baby weighing 
more than 9 pounds? 

Based on the results of these tests, you may be eligible for up 
to two diabetes screenings every year. No cost for the test, 
but you generally have to pay 20% of the Medicare-approved 
amount for the doctor s visit. 



Diabetes For people with diabetes. Your doctor or other health care 

Self-Management provider must provide a written training order. You pay 20% 
Training of the Medicare-approved amount, and the Part B deductible 

applies. 



Diabetes Supplies 



Including blood sugar testing monitors, blood sugar test 
strips, lancet devices and lancets, blood sugar control 
solutions, and therapeutic shoes (in some cases). Insulin is 
covered only if used with an insulin pump. You pay 20% of 
the Medicare-approved amount, and the Part B deductible 
applies. 

Note: Insulin and certain medical supplies used to inject 
insulin, such as syringes, may be covered by Medicare 
prescription drug coverage (Part D). 



Part B deductible and coinsurance amounts are on page 121. 



30 



Section 1— What's Covered? (Part A and Part B) 



Part B-Covered Services 



v 



Doctor 
Services 


Services that are medically necessary (includes outpatient and 
some doctor services you get when you are a hospital inpatient) 
or covered preventive services. Doesn't cover routine physicals 
except for the one-time "Welcome to Medicare" physical exam. 
See page 33. You pay 20% of the Medicare-approved amount, and 
the Part B deductible applies. 


Durable 
Medical 
Equipment 
(like walkers) 


Items such as oxygen equipment and supplies, wheelchairs, 
walkers, and hospital beds ordered by your doctor for use in 
the home. Some items must first be rented. You pay 20% of the 
Medicare-approved amount, and the Part B deductible applies. 
You must get your covered equipment or supplies from a supplier 
enrolled in Medicare. 

For more information, visit 

www.medicare.gov/Publications/Pubs/pdf/ 1 1045.pdf to view 
"Medicare Coverage of Durable Medical Equipment and Other 
Devices." 


Emergency 

Room 

Services 


When you believe your health is in serious danger. You may have 
a bad injury, a sudden illness, or an illness that quickly gets much 
worse. You pay a specified copayment for the hospital emergency 
department visit, and you pay 20% of the Medicare-approved 
amount for the doctors services. The Part B deductible applies. 


Eye Exams for 
People with 
Diabetes 


For people with diabetes to check for diabetic retinopathy 
once every 12 months. You pay 20% of the Medicare-approved 
amount, and the Part B deductible applies. 


Eyeglasses 
(limited) 


One pair of eyeglasses with standard frames (or one set of 
contact lenses) after cataract surgery that implants an intraocular 
lens. You pay 20% of the Medicare-approved amount, and the 
Part B deductible applies. 


Federally- 
Qualified 
Health Center 
Services 


Provides a broad range of outpatient primary care and preventive 
services. You pay 20% of the Medicare-approved amount. 


Flu Shots 


Helps prevent influenza or flu virus. This is covered once a flu 
season in the fall or winter. You need a flu shot for the current 
virus each year. No cost to you for the flu shot if the doctor 
accepts assignment (see page 47) for giving the shot. 



Part B deductible and coinsurance amounts are on page 121. 



Section 1— What's Covered? (Part A and Part B) 



31 



Part B-Covered Services 



Foot Exams and 
Treatment 


If you have diabetes-related nerve damage and/or meet certain 
conditions. You pay 20% of the Medicare-approved amount, 
and the Part B deductible applies. 


Glaucoma Tests 


Helps find the eye disease glaucoma. This is covered once 
every 12 months for people at high risk for glaucoma. You are 
considered high risk for glaucoma if you have diabetes, or a 
family history of glaucoma, or are African- American and age 
50 or older, or are Hispanic and age 65 or older. Tests must be 
done by an eye doctor who is legally authorized by the state. 
You pay 20% of the Medicare-approved amount, and the Part B 
deductible applies. 


Hearing and 
Balance Exams 


If your doctor orders it to see if you need medical treatment. 
Hearing aids and exams for fitting hearing aids aren't covered. 
You pay 20% of the Medicare-approved amount, and the Part B 
deductible applies. 


Hepatitis B 
Shots 


Helps protect people from getting Hepatitis B. This is covered 
for people at high or medium risk for Hepatitis B. Your risk for 
Hepatitis B increases if you have hemophilia, End- Stage Renal 
Disease (ESRD), or a condition that lowers your resistance to 
infection. Other factors may increase your risk for Hepatitis B, 
so check with your doctor about your risk. You pay 20% of the 
Medicare-approved amount, and the Part B deductible applies. 


Home Health 
Services 


Limited to medically-necessary part-time or intermittent 
skilled nursing care or physical therapy, or speech-language 
pathology, or a continuing need for occupational therapy. Must 
be ordered by a doctor and provided by a Medicare -certified 
home health agency. Home health services may also include 
medical social services, part-time or intermittent home health 
aide services, durable medical equipment (see page 30) and 
medical supplies for use at home. You must be homebound, 
which means that leaving home takes a lot of effort. No cost to 
you for home health services. For Medicare-covered durable 
medical equipment, you pay 20% of the Medicare-approved 
amount, and the Part B deductible applies. 



^ 



V 



Part B deductible and coinsurance amounts are on page 121. 



32 



Section 1— What's Covered? (Part A and Part B) 



Part B-Covered Services 



j 



Kidney 
Dialysis 
Services and 
Supplies 


For people with ESRD. Dialysis is covered either in a facility 
or at home when your doctor orders it. You pay 20% of the 
Medicare -approved amount, and the Part B deductible applies. 


Mammograms 
(screening) 


A type of X-ray to check women for breast cancer before they 
or their doctor may be able to find it. Screening mammograms 
are covered once every 12 months for all women with Medicare 
age 40 and older. Medicare covers one baseline mammogram 
for women between age 35 and 39. You pay 20% of the 
Medicare-approved amount. 


Medical 
Nutrition 
Therapy 
Services 


Medicare may cover medical nutrition therapy and certain 
related services if you have diabetes or kidney disease, and 
your doctor refers you for the service. You pay 20% of the 
Medicare-approved amount, and the Part B deductible applies. 


Mental 
Health Care 
(outpatient) 

© 


To get help with mental health conditions such as depression, 
anxiety, or substance abuse. Includes services generally given 
outside a hospital or in a hospital outpatient department, 
including visits with a doctor, psychiatrist, clinical psychologist, 
or clinical social worker, and lab tests. Certain limits and 
conditions apply. For doctor or other health care provider visits 
to diagnose, or to monitor or change your prescription, you pay 
20% of the Medicare- approved amount. For outpatient treatment 
of your mental health condition (such as therapy), you pay 50% 
of the Medicare-approved amount. The Part B deductible applies. 

Talk to your doctor if you feel sad, have little interest in things 
you used to enjoy, feel dependent on drugs or alcohol, or 
have thoughts about ending your life. See page 120 for more 
information about inpatient mental health care. 


Occupational 
Therapy 


Evaluation and treatment to help you return to usual activities 
(such as dressing or bathing) after an illness or accident when 
your doctor certifies you need it. In 2009, there may be limits 
on physical therapy, occupational therapy, and speech-language 
pathology services and exceptions to these limits. You pay 20% 
of the Medicare-approved amount, and the Part B deductible 
applies. 



Part B deductible and coinsurance amounts are on page 121. 



Section 1— What's Covered? (Part A and Part B) 



33 



Part B-Covered Services 



tt 



Outpatient 

Hospital 

Services 


Services you get as an outpatient as part of a doctors care. You pay 
a specified copayment for each service. The copayment can't be 
more than the Part A hospital stay deductible. See page 120. The 
Part B deductible applies. 


Outpatient 
Medical and 
Surgical 
Services and 
Supplies 


For approved procedures (like X-rays, a cast, or stitches). You 
pay a copayment for each service you get in an outpatient 
hospital setting. For each service, this amount can't be more than 
the Part A hospital stay deductible. See page 120. The Part B 
deductible applies, and you pay all charges for items or services 
that Medicare doesn't cover. 


Pap Tests and 
Pelvic Exams 
(includes clinical 
breast exam) 


Checks for cervical, vaginal, and breast cancers. Medicare covers 
these screening tests once every 24 months, or once every 12 
months for women at high risk, and for women of child-bearing 
age who have had an exam that indicated cancer or other 
abnormalities in the past 3 years. No cost to you for the Pap lab 
test. You pay 20% of the Medicare-approved amount for Pap test 
collection, and pelvic and breast exams. 


Physical Exam 
(one-time 
"Welcome 
to Medicare" 
physical exam) 


A one-time review of your health, and education and counseling 
about preventive services, including certain screenings, shots, and 
referrals for other care if needed. 

New: Starting January 1, 2009, Medicare will cover this exam if 
you get it within the first 12 months you have Part B. You pay 20% 
of the Medicare-approved amount, and the Part B deductible no 
longer applies. 

Important: In 2008, you had to get the physical exam within the 
first 6 months you had Part B, and the Part B deductible applied. 


Physical 
Therapy 


Evaluation and treatment for injuries and diseases that change 
your ability to function when your doctor certifies your need for 
it. In 2009, there may be limits on these services and exceptions to 
these limits. You pay 20% of the Medicare-approved amount, and 
the Part B deductible applies. 


Pneumococcal 
Shot 


Helps prevent pneumococcal infections (like certain types of 
pneumonia). Most people only need this preventive shot once 
in their lifetime. Talk with your doctor. No cost if the doctor or 
supplier accepts assignment (see page 47) for giving the shot. 



* 



^ 



Part B deductible and coinsurance amounts are on page 121. 



Section 1— What's Covered? (Part A and Part B) 



Part B-Covered Services 



* 



Practitioner 

Services 

(Non-doctor) 


Such as services provided by physician assistants and nurse 
practitioners. You pay 20% of the Medicare-approved amount, 
and the Part B deductible applies. 


Prescription 
Drugs (limited) 


Includes a limited number of prescription drugs such as those 
you get in a hospital outpatient department under certain 
circumstances, injected drugs you get in a doctors office, certain 
oral cancer drugs, and drugs used with some types of durable 
medical equipment (like a nebulizer or infusion pump). You pay 
20% of the Medicare -approved amount, and the Part B deductible 
applies. Note: Other than the examples above, under Part B, you 
pay 100% for most prescription drugs, unless you have Part D or 
other drug coverage. For more information, see pages 63-71. 


Prostate Cancer 
Screenings 


Helps detect prostate cancer. Medicare covers a digital rectal 
exam and Prostate Specific Antigen (PSA) test once every 12 
months for all men with Medicare over age 50. You pay 20% 
of the Medicare-approved amount, and the Part B deductible 
applies for the doctor's visit. No cost to you for the PSA test. 


Prosthetic/ 
Orthotic Items 


Including arm, leg, back, and neck braces; artificial eyes; artificial 
limbs (and their replacement parts); breast prostheses (after 
mastectomy); and prosthetic devices needed to replace an internal 
body part or function (including ostomy supplies, and parenteral 
and enteral nutrition therapy) when ordered by a doctor. For 
Medicare to cover your prosthetic or orthotic, you must go 
to a supplier that is enrolled in Medicare. You pay 20% of the 
Medicare-approved amount, and the Part B deductible applies. 


Rural Health 
Clinic Services 


Provides a broad range of outpatient primary care services. 
You pay 20% of the amount charged, and the Part B deductible 
applies. 


Second Surgical 
Opinions 


Covered in some cases for surgery that isn't an emergency. In 
some cases, Medicare covers third surgical opinions. You pay 
20% of the Medicare-approved amount, and the Part B deductible 
applies. 


Smoking 
Cessation 
(counseling to 
stop smoking) 


Includes up to 8 face-to-face visits in a 12-month period if you 
are diagnosed with an illness caused or complicated by tobacco 
use, or you take a medicine that is affected by tobacco. You pay 
20% of the Medicare -approved amount, and the Part B deductible 
applies. 



Part B deductible and coinsurance amounts are on page 121. 



Section 1— What's Covered? (Part A and Part B) 



35 



Part B-Covered Services 



Speech-Language 

Pathology 

Services 


Evaluation and treatment given to regain and strengthen 
speech and language skills including cognitive and 
swallowing skills when your doctor certifies your need for it. 
In 2009, there may be limits on these services and exceptions 
to these limits. You pay 20% of the Medicare -approved 
amount, and the Part B deductible applies. 


Surgical Dressing 
Services 


For treatment of a surgical or surgically- treated wound. You 
pay 20% of the Medicare -approved amount, and the Part B 
deductible applies. 


Telemedicine 


Medical or other health services given to a patient using 
a communications system (like a computer, telephone, 
or television) by a provider in a location different from 
the patient s. Available in some rural areas, under certain 
conditions and only in a provider's office, a hospital, or 
a federally- qualified health center. You pay 20% of the 
Medicare-approved amount, and the Part B deductible 
applies. 


Tests 


Including X-rays, MRIs, CT scans, EKGs, and some other 
diagnostic tests. You pay 20% of the Medicare -approved 
amount, and the Part B deductible applies. See "Clinical 
Laboratory Services" on page 27 for other Part B-covered 
tests. If you get the test as a hospital outpatient, you pay 
a specified copayment that may be more than 20% of the 
Medicare-approved amount but cant be more than the 
Part A hospital stay deductible. See page 120. 



Part B deductible and coinsurance amounts are on page 121. 



36 



Section 1— What's Covered? (Part A and Part B) 



Part B-Covered Services 



Transplants and 

Immunosuppressive 

Drugs 



Including doctor services for heart, lung, kidney, pancreas, 
intestine, and liver transplants under certain conditions 
and only in a Medicare -certified facility. Bone marrow and 
cornea transplants are covered under certain conditions. 

Immunosuppressive drugs are covered if Medicare paid 
for the transplant, or an employer or union group health 
plan that was required to pay before Medicare paid for the 
transplant. You must have been entitled to Part A at the 
time of the transplant and entitled to Part B at the time you 
get immunosuppressive drugs, and the transplant must 
have been performed in a Medicare-certified facility. You 
pay 20% of the Medicare-approved amount, and the Part B 
deductible applies. 

If you are thinking of joining a Medicare Advantage Plan 
and are on a transplant waiting list or believe you need a 
transplant, check with the plan before you join to make 
sure your doctors and hospitals are in the plan's network. 
Also, check the plans coverage rules. 

Note: Medicare drug plans (Part D) may cover 
immunosuppressive drugs, even if Medicare or an 
employer or union group health plan didn't pay for the 
transplant. 



Part B deductible and coinsurance amounts are on page 121. 



Section 1— What's Covered? (Part A and Part B) 



37 



Part B-Covered Services 



Travel (health 
care needed 
when traveling 
outside the 
United States) 



Urgently- 
Needed Care 



Medicare generally doesn't cover health care while you are 
traveling outside the U.S. (the "U.S." includes the 50 states, the 
District of Columbia, Puerto Rico, the Virgin Islands, Guam, 
the Northern Mariana Islands, and American Samoa). There 
are some exceptions including some cases where Medicare 
may pay for services that you get while on board a ship within 
the territorial waters adjoining the land areas of the U.S. In 
rare cases, Medicare may pay for inpatient hospital, doctor, 
or ambulance services you get in a foreign country in the 
following situations: 

1) If an emergency arose within the U.S. and the foreign 
hospital is closer than the nearest U.S. hospital that can treat 
your medical condition 

2) If you are traveling through Canada without unreasonable 
delay by the most direct route between Alaska and another 
state when a medical emergency occurs and the Canadian 
hospital is closer than the nearest U.S. hospital that can treat 
the emergency 

3) If you live in the U.S. and the foreign hospital is closer to 
your home than the nearest U.S. hospital that can treat your 
medical condition, regardless of whether an emergency exists 

You pay 20% of the Medicare-approved amount, and the Part B 
deductible applies. 



To treat a sudden illness or injury that isn't a medical 
emergency. You pay 20% of the Medicare-approved amount, 
and the Part B deductible applies. 



Part B deductible and coinsurance amounts are on page 121. 



115-118. 



38 Section 1 —What's Covered? (Part A and Part B) 

What's NOT Covered by Part A and Part B? 

Items and services that Medicare doesn't cover include, but aren't 
limited to, the following: 

■ Acupuncture. 

■ Chiropractic services (except as listed on page 27). 

■ Cosmetic surgery. 

■ Custodial care, except when you also get skilled nursing care in a 
skilled nursing facility, at home, or as part of hospice care. 

■ Deductibles, coinsurance, or copayments when you get certain health 
care services. See pages 120-121 for these amounts. People with 
limited income and resources may get help paying these costs. See 

Blue words pages 82-84. 

in the text ■ Dental care and dentures (with a few exceptions). 

are defined m £y e exams (routine), eye refractions (exam that measures how well you 

on P a 9 es see at specific distances), and eyeglasses (except as listed on page 30). 

■ Foot care (routine), like cutting corns or calluses (with few 
exceptions). See page 31. 

■ Hearing aids and exams for the purpose of fitting a hearing aid. 

■ Hearing tests that haven't been ordered by your doctor. 

■ Laboratory tests (screening), except those listed on pages 26-35. 

■ Long-term care. See pages 102-104. 

■ Orthopedic shoes (with few exceptions). See page 29 under Diabetes 
Supplies. 

■ Physical exams (routine or yearly). Medicare will cover a one-time 
physical exam. See page 33. 

■ Prescription drugs (with few exceptions). See page 34. See pages 63-71 
for information about Medicare prescription drug coverage (Part D). 

■ Shots to prevent illness, except as listed on pages 30, 31, and 33. Part D 
must cover all commercially- available vaccines (like the shingles 
vaccine) except those covered by Part B. 

■ Surgical procedures given in ambulatory surgical centers that aren't 
included on Medicare's list of ambulatory surgical center covered 
procedures. 

■ Syringes or insulin. Insulin used with an insulin pump is covered by 
Part B. Syringes or insulin may be covered by Part D. 

■ Travel (health care while you're traveling outside the United States, 
except as listed on page 37). 



Section 1— What's Covered? (Part A and Part B) 



39 



* 



Preventive Services Checklist 

Take this checklist to your doctor or other health care provider, and 
ask which preventive services are right for you. Look on pages 25-34 
for more details about the costs, how often, and whether you meet 
the conditions to get these services. Write down any notes (like the 
date you get the service). 



Medicare-covered Preventive Service 


Details 
on Page 


Notes 




Abdominal Aortic Aneurysm 
Screening 


26 






Bone Mass Measurement 


27 






Cardiovascular Screenings 


27 






Colorectal Cancer Screenings 








Fecal Occult Blood Test 


28 






Flexible Sigmoidoscopy 


28 






Colonoscopy 


28 






Barium Enema 


28 






Diabetes Screenings 


29 






Diabetes Self- Management Training 


29 






Flu Shots 


30 






Glaucoma Tests 


31 






Hepatitis B Shots 


31 






Mammogram (screening) 


32 






Medical Nutrition Therapy Services 


32 






Pap Test and Pelvic Exam (includes 
breast exam) 


33 






Physical Exam (one-time "Welcome 
to Medicare" physical exam) 


33 






Pneumococcal Shot 


33 






Prostate Cancer Screenings 


34 






Smoking Cessation (counseling to 
stop smoking) 


34 





Visit www.MyMedicare.gov to keep track of your preventive services. See page 109. 



40 Section 1 —What's Covered? (Part A and Part B) 

Notes 



Decide How 
to Get Your 
Medicare 



SECTION 2 



41 




You have choices about how you get your Medicare health and 
prescription drug coverage. Before making any decisions, learn 
as much as you can about the types of coverage available to you. 

Section 2 includes information about the following: 

Your Medicare Choices 42-44 

Original Medicare 45-49 

Medicare Advantage Plans (Part C) 50-60 

Other Medicare Health Plans 61-62 

Medicare Prescription Drug Coverage (Part D) 63-73 

How Your Bills Get Paid If You Have Other 
Health Insurance 74 

Medigap (Medicare Supplement Insurance) Policies .... 75-76 

This handbook has basic information. You may need more 
detailed information than this handbook provides to make a 
choice. See page 42 to find out how to get personalized health 
insurance counseling. 



42 Section 2 — Decide How to Get Your Medicare 

Your Medicare Choices 

You can choose different ways to get your Medicare coverage, 
Original Medicare or a Medicare Advantage Plan (like an HMO 
or PPO). If you choose Original Medicare and you want drug 
coverage, you can join a Medicare Prescription Drug Plan. If you 
choose to join a Medicare Advantage Plan, the plan may include 
Medicare prescription drug coverage. In most cases, if you don't 
make a choice, you will have Original Medicare. See page 43 for 
more information about your coverage choices and the decisions 
you need to make. 

Each year you should review your health and prescription needs 
because your health, finances, or coverage may have changed. If you 
decide other coverage will better meet your needs, you can switch 
plans during certain times. See pages 59 and 65. 

Need Help Deciding? 

Blue words 1- Visit www.medicare.gov and select, "Compare Health Plans 

in the text an d Medigap Policies in Your Area" or "Compare Medicare 

are defined Prescription Drug Plans." 

on pages 2. Get free counseling about choosing coverage. See pages 111-114 

115-118. for the telephone number of your State Health Insurance 

Assistance Program (SHIP). 
3. Call 1-800-MEDICARE (1-800-633-4227), and say "Agent." 

TTY users should call 1-877-486-2048. 



Section 2 — Decide How to Get Your Medicare 



43 



Use These Steps to Help You Decide 





Stepl 




Decide if You Want 


Original Medicare OR a Medicare Advantage Plan 


(like an HMO or PPO) 


Part A (Hospital Insurance) and 




Part C— Includes BOTH Part A (Hospital 


Part B (Medical Insurance) 




Insurance) and Part B (Medical Insurance) 


■ Medicare provides this coverage. 




■ Private insurance companies approved by 


■ You have your choice of doctors, hospitals, 




Medicare provide this coverage. 


and other providers. 




■ In most plans, you need to use plan doctors, 


■ Generally, you pay deductibles and 




hospitals, and other providers or you pay more. 


coinsurance. 




■ You usually pay a monthly premium (in 


■ You usually pay a monthly premium for 




addition to your Part B premium) and a 


Part B. 




copayment for covered services. 


See pages 45-49. 




■ Costs, extra coverage, and rules vary by plan. 
See pages 50-60. 


■ step 2 II 




■ Step 2 ■ 


Decide If You Want Pres 


cription Drug Coverage (Part D) 


■ If you want this coverage, you must choose 




■ If you want this coverage, in most cases you 


and join a Medicare Prescription Drug 




must get it through your Medicare Advantage 


Plan. 




Plan. 


■ These plans are run by private companies 




■ Most Medicare Advantage Plans include 


approved by Medicare. 




prescription drug coverage (Part D), usually 


See pages 63-71 






for an extra cost. 




1 Step 3 ■ 




See pages 54-56. 




Decide If You Want Supplemental Coverage 


You may want to get private coverage that fills 




gaps in Original Medicare coverage. 


Note: If you join a Medicare Advantage 


■ You can choose to buy private 


Plan, you don't need a Medigap policy. If you 


supplemental coverage, like a Medigap 


already have a Medigap policy, you can't use 


(Medicare Supplement Insurance) policy. 


it to pay for any expenses you have under 


■ Costs vary by policy and company. 


the Medicare Advantage Plan. If you already 


■ Employers/unions may offer similar 


have a Medicare Advantage Plan, you can't 


coverage. 


be sold a Medigap policy. See page 57. 


See pages 75-76. 







In addition to Original Medicare or a Medicare Advantage Plan, you may be able to join other 
types of Medicare health plans (see pages 61-62). You may be able to save money or have other 
choices if you have limited income and resources (see pages 77-84). You may also have other 
coverage, like employer or union, military, or Veterans' benefits (see pages 72-73). 



44 



Section 2 — Decide How to Get Your Medicare 




Blue words 
in the text 
are defined 
on pages 
115-118. 



Q 



Things to Consider When Choosing or Changing 
Your Coverage 

■ Coverage — When choosing between Original Medicare and a 
Medicare health plan, does the plan provide extra coverage you want 
that Original Medicare doesn't cover? 

■ Your other coverage — Do you have, or are you eligible for, other 
types of health or prescription drug coverage? If so, read the 
materials you get from your insurer or plan, or call them to find out 
how the coverage works with, or is affected by, Medicare. If you have 
coverage through a former or current employer or union, talk to your 
benefits administrator, insurer, or plan before making any changes to 
your coverage. 

■ Cost — How much are your premiums and deductibles? How much 
do you pay for services like hospital stays or doctor visits? Your costs 
vary and may be different if you don't follow the coverage rules. 

■ Doctor and hospital choice — Do your doctors accept the coverage? 
Are they accepting new patients? If you are considering a Medicare 
health plan, do you have to choose your hospital and health care 
providers from a network? Do you need a referral to see a specialist? 

■ Prescription drugs — What are your drug needs? Do you need to 
join a Medicare drug plan? What will your prescription drugs cost 
under each plan? Are your drugs covered under the plan's formulary 
(drug list)? Formularies can change. 

■ Quality of care — The quality of care and services given by plans and 
other health care providers can vary. Medicare has information to 
help you compare plans and providers. See page 100. 

■ Convenience — Where are the doctors' offices? What are their hours? 
Which pharmacies can you use? Can you get your prescriptions by 
mail? 

■ Travel — Do you spend part of each year in another state? Will the 
plan cover you there? 

Your Medicare plan will send you an Evidence of Coverage 
(EOC) and Annual Notice of Change (ANOC) each year. The 
EOC gives you details about what the plan covers, how much 
you pay, and more. The ANOC includes any changes in coverage, 
costs, or service area that will be effective in January. 



Section 2 — Decide How to Get Your Medicare 



45 



Original Medicare 

Original Medicare is one of your health coverage choices as part of 
Medicare. You will have Original Medicare unless you choose to 
join a Medicare health plan. 

How Does Original Medicare Work? 

Under Original Medicare, you have your choice of doctors and 
hospitals. You don't need a referral. You pay a separate amount for 
each service. Here are the general rules for how it works: 





Original Medicare 


Are prescription drugs 
covered? 


Only in limited situations like when you are a hospital inpatient. 
See pages 20 and 34. You can add comprehensive drug coverage by 
joining a Medicare Prescription Drug Plan. See pages 63-71. 


Do 1 need to choose a 
primary care doctor? 


No. 


Can 1 get my health 
care from any doctor 
or hospital? 


Yes. You can go to any doctor, supplier, hospital, or other facility that 
is enrolled in Medicare and is accepting new Medicare patients. 


Do 1 have to get 
a referral to see a 
specialist? 


No. 


Do 1 need a 
supplemental policy? 


You may already have employer or union coverage that may pay 
costs that Original Medicare doesn't. If not, you may want to buy a 
Medigap (Medicare Supplement Insurance) policy. See pages 75-76. 


What else do 1 need to 
know about Original 
Medicare? 


■ Each year, you generally must pay a set amount for your health care 
(deductible) before Medicare pays its share. Then, Medicare pays 
its share, and you pay your share (coinsurance) for covered services 
and supplies. See pages 120-121 to find out what you pay. 

■ If you have Part A, you can generally get the Part A-covered 
services listed on pages 19-20. 

■ If you have Part B, you can generally get the services listed on 
pages 26-37. You usually pay a monthly premium for Part B. 
Seepage 119. 

■ You generally don't need to file Medicare claims. Providers (like 
doctors, hospitals, skilled nursing facilities, and home health 
agencies) and suppliers are required by law to file Medicare claims 
for the covered services and supplies you get. 



46 



Section 2 — Decide How to Get Your Medicare 




© 



Original Medicare Payment Information 

If you get a Medicare- covered service, you will get a Medicare 
Summary Notice (MSN) in the mail. The MSN shows all the services 
or supplies that were billed to Medicare during each 3-month period, 
what Medicare paid, and what you may owe the provider. The MSN 
isn't a bill. When you get your MSN, you should do the following: 

■ If you have other insurance, check to see if it covers anything that 
Medicare didn't. 

■ Keep your receipts and bills, and compare them to your MSN to be 
sure you got all the services, supplies, or equipment listed. 

■ If you paid a bill before you got your MSN, compare your MSN with 
the bill to make sure you paid the right amount for your services. 

MSNs are mailed every 3 months. If you are due a refund check from 
Medicare, the MSN will be mailed as soon as the claim is processed. 
If you need to change your address on your MSN, call Social Security 
at 1-800-772-1213. TTY users should call 1-800-325-0778. If you 
get RRB benefits, call your local RRB office or 1-800-808-0772. After 
January 1, 2009, call 1-877-772-5772. 

Visit www.MyMedicare.gov to track your Medicare claims. 
See page 109. 

Your Out-of-Pocket Costs in Original Medicare 
Depend on the Following: 

■ Whether you have Part A and/or Part B (most people have both). 

■ Whether your doctor or supplier accepts "assignment." See page 47. 

■ How often you need health care. 

■ What type of health care you need. 

■ Whether you choose to get services or supplies Medicare doesn't 
cover. If you do, you pay all the costs for these services. 

■ Whether you have other health insurance that works with Medicare. 

■ Whether you have Medicaid or get state help paying your Medicare 
costs. See pages 82-83. 

See pages 75-84 for more information about help to cover the 
costs that Original Medicare doesn't cover. 



Section 2 — Decide How to Get Your Medicare 



47 



// 





Blue words 
in the text 
are defined 
on pages 
115-118. 






Assignment" in Original Medicare 

Assignment is an agreement between you, Medicare, and doctors, 
other health care providers, or suppliers. When you "assign" a 
claim, Medicare will pay the doctor, provider, or supplier directly 
for the services you get. 

Remember the following if your doctor, provider, or supplier 
accepts assignment: 

■ Your out-of-pocket costs may be less. 

■ Most doctors, providers, and suppliers accept assignment, but 
you should always check to make sure. In some cases they must 
accept assignment, like when they have a participation agreement 
with Medicare and give you Medicare-covered services. 

■ If a doctor, provider, or supplier accepts assignment, they agree 
to only charge you the Medicare deductible or coinsurance 
amount and wait for Medicare to pay its share. 

■ All doctors, providers, and suppliers that give you 
Medicare-covered services have to submit your claim to 
Medicare directly. They can't charge you for submitting the claim. 

Remember the following if your doctor, provider, or supplier 
doesn't accept assignment: 

■ They still must submit a claim to Medicare when they give you 
Medicare-covered services. If they don't submit the claim for 
these services, you should contact the company that handles 
bills for Medicare for your state to file a complaint. Look on your 
MSN for the telephone number. In the meantime, you might 
have to pay the entire charge at the time of service, and then 
submit your claim to Medicare to get paid back. 

■ They may charge you more than the Medicare-approved amount, 
but there is a limit called "the limiting charge." They can only 
charge you up to 15% over the Medicare-approved amount. The 
limiting charge applies only to certain services and doesn't apply 
to some supplies and durable medical equipment. 

To find doctors and suppliers who accept assignment, visit 
www.medicare.gov and select, "Find a Doctor or Other Healthcare 
Professional" or "Find Suppliers of Medical Equipment in Your 
Area." You can also call 1-800-MEDICARE. 



48 Section 2 — Decide How to Get Your Medicare 

What Is a Private Contract? 

A "private contract" is a written agreement between you and a 
doctor or other health care provider who has decided not to provide 
services through Medicare. The private contract only applies to the 
services provided by the doctor who asked you to sign it. You can't be 
asked to sign a private contract in an emergency situation or when 
you need urgent care. You don't have to sign a private contract with 
a doctor. You can go to another doctor who will provide services 
through Medicare. If you sign a private contract with your doctor, 
remember these rules: 

■ Medicare won't pay any amount for the services you get from this 
doctor. 

■ You will have to pay whatever this doctor or provider charges you 
for the services you get. 

■ If you have a Medigap (Medicare Supplement Insurance) policy, it 
won't pay anything for this service. Call your Medigap insurance 
company before you get the service if you have questions. 

■ Your doctor must tell you if Medicare would pay for the service if 
you got it from another doctor who accepts Medicare. 

■ Your doctor must tell you if he or she has been excluded from 
Medicare. 

You are always free to get non-covered services on your own if 
you choose to pay for the service yourself. See page 38 for a list of 
services and items that Medicare doesn't cover. 

You may want to contact your State Health Insurance Assistance 
Program (SHIP) to get help before signing a private contract with 
any doctor or other health care provider. See pages 1 1 1-1 14 for the 
telephone number. 



O 



See pages 85-98 for information about your appeal rights and 
how to protect yourself and Medicare from fraud. 



Section 2 — Decide How to Get Your Medicare 



49 



© 




Blue words 
in the text 
are defined 
on pages 
115-118. 



Adding Medicare Prescription Drug Coverage 
(Part D) 

If you have Original Medicare and you want Medicare drug 
coverage, you must join a Medicare Prescription Drug Plan. These 
plans are available through private companies that work with 
Medicare to provide prescription drug coverage. See pages 63-71 
for more details about Medicare prescription drug coverage. 

Call your employer or unions benefits administrator before 
you make any changes to your coverage. If you drop your 
employer or union coverage, you may not be able to get it 
back. You also may not be able to drop your employer or 
union drug coverage without also dropping your employer 
or union health (doctor and hospital) coverage. If you drop 
coverage for yourself, you may also have to drop coverage for 
your spouse and dependants. 

Help Paying for a Medicare Drug Plan 

People with limited income and resources may qualify for "extra 
help" paying their Medicare prescription drug coverage costs. If 
you automatically qualify for "extra help," you won't pay a premium 
if you join certain Medicare drug plans. If you don't automatically 
qualify, you may still get help to pay your prescription drug costs. 
See pages 78-81 to find out if you may qualify for "extra help." 



50 Section 2 — Decide How to Get Your Medicare 

Medicare Advantage Plans (Part C) 

Medicare Advantage Plans are health plan options (like an HMO 
or PPO) approved by Medicare and offered by private companies. 
These plans are part of Medicare and are sometimes called 
"Part C" or "MA Plans." Medicare pays a fixed amount for your 
care every month to the companies offering Medicare Advantage 
Plans. These companies must follow rules set by Medicare. 
Medicare Advantage Plans provide your Medicare health 
coverage and usually Medicare drug coverage. They aren't 
supplemental insurance. 

Not all Medicare Advantage Plans work the same way, so find out 
the plan's rules before joining. See the chart that starts on page 54 
for an outline of these various plans' rules. In all plan types, you 
are always covered for emergency and urgent care. 

Medicare Advantage Plans include the following: 

■ Preferred Provider Organization (PPO) Plans. See page 54. 

■ Health Maintenance Organization (HMO) Plans. See page 54. 

■ Private Fee-for-Service (PFFS) Plans. See page 55. 

■ Medical Savings Account (MSA) Plans. See page 55. 

■ Special Needs Plans (SNP). See page 56. 

Note: There are other types of Medicare Advantage Plans that may 
be available; however, they are less common. Provider Sponsored 
Organizations (PSOs) are plans run by a provider or group of 
providers. In a PSO, you usually get your health care from the 
providers who are a part of the plan. Religious Fraternal Benefit 
(RFB) Plans are offered to members of certain religious groups. 
RFBs can be any plan type, including an HMO or PPO. 



Section 2 — Decide How to Get Your Medicare 



51 




Blue words 
in the text 
are defined 
on pages 
115-118. 



Medicare Advantage Plans (Part C) (continued) 

Medicare Advantage Plans provide all of your Part A (Hospital 
Insurance) and Part B (Medical Insurance) coverage. This means 
they must cover at least all of the services that Original Medicare 
covers. However, each Medicare Advantage Plan can charge 
different out-of-pocket costs. These are usually copayments but can 
also be coinsurance and deductibles. It's important to call any plan 
before joining to find out the plan's rules, what your costs will be, 
and to make sure the plan meets your needs. 

Medicare Advantage Plans may offer extra coverage, such as 
vision, hearing, dental, and/or health and wellness programs. Most 
include Medicare prescription drug coverage (usually for an extra 
cost). You may need a referral to see specialists. Some Medicare 
Advantage Plans have provider networks. In some cases this means 
you can only see doctors who belong to the plan or go to certain 
hospitals to get covered services (other than for emergency or 
urgently needed care or medically-necessary dialysis). 

In some plans, if you see a doctor or other provider who doesn't 
contract or participate with the plan, your services may not be 
covered at all, or your costs will likely be higher. You should check 
with your doctors or hospital to find out if they accept the plan. 

Who Can Join? 

You can generally join a Medicare Advantage Plan if you meet these 
conditions: 

■ You have Part A and Part B. 

■ You live in the service area of the plan. Contact the plans you're 
interested in to find out about the service area. Visit 
www.medicare.gov, or call 1-800-MEDICARE (1-800-633-4227) 
to find plans in your area. TTY users should call 1-877-486-2048. 

■ You don't have End-Stage Renal Disease (ESRD) (permanent 
kidney failure requiring dialysis or a kidney transplant) except as 
explained on page 58. 

Note: In most cases, you can join a Medicare Advantage Plan only 
at certain times during the year. See page 59. 



52 Section 2 — Decide How to Get Your Medicare 

More About Medicare Advantage Plans 

■ As with Original Medicare, you still have Medicare rights and 
protections, including the right to appeal. See pages 86-89. 

■ Check with the plan before you get a service to find out whether 
they will cover the service and what your costs may be. 

■ You must follow plan rules, like getting a referral to see a 
specialist or getting prior approval for certain procedures to avoid 

Blue words higher costs. Check with the plan. 

in the text ■ You can join a Medicare Advantage Plan even if you have a 

are defined pre-existing condition, except for End-Stage Renal Disease, 

on pages See page 58. 

115-118. m you can only join a plan during one of the periods listed on 

page 59. In most cases, you are enrolled in a plan for a year. 

■ If you see a doctor who doesn't belong to the plan, your services 
may not be covered, or your costs could be higher, depending on 
the type of Medicare Advantage Plan. 

■ If the plan decides to stop participating in Medicare, you will 
have to join another Medicare health plan or return to Original 
Medicare. See page 59. 

■ You usually get prescription drug coverage (Part D) through 
the plan. In most cases, if you are in a Medicare Advantage 
Plan that includes prescription drug coverage and you join 
a Medicare Prescription Drug Plan, you will be disenrolled 
from your Medicare Advantage Plan and returned to Original 
Medicare. 

■ You don't need to buy (and can't be sold) a Medigap (Medicare 
Supplement Insurance) policy. It won't cover your Medicare 
Advantage Plan deductibles, copayment, or coinsurance. 



© 



See pages 85-97 for information about your appeal rights and 
how to protect yourself and Medicare from fraud. 



Section 2 — Decide How to Get Your Medicare 



Your Out-of-Pocket Costs in a Medicare 
Advantage Plan Depend on the Following: 

■ Whether the plan charges a monthly premium in addition to your 
Part B premium. Medicare Advantage Plans charge one combined 
premium for Part A and Part B health coverage, Medicare 
prescription drug coverage (Part D) (if offered), and extra coverage 
(if offered). 

■ Whether the plan pays any of the monthly Part B premium (see 
"Saving on Your Part B Premium" below). 

■ Whether the plan has a yearly deductible or any additional 
deductibles. 

■ How much you pay for each visit or service (copayments). 

■ The type of health care services you need and how often you get 
them. 

■ Whether you follow the plan's rules, like using network providers. 

■ Whether you need extra coverage and what the plan charges for it. 

To learn more about your costs in specific Medicare Advantage 
Plans, contact the plans you are interested in to get more details. 

Saving on Your Part B Premium 

There are two ways to save on your Part B premium: 

■ A few Medicare Advantage Plans may pay all or part of your Part B 
premium. You still get all Part A and Part B-covered services. 

■ You can also call your State Medical Assistance (Medicaid) office 
if you have limited income and resources to see if you can get help 
paying your Part B premium costs. See page 83. 

Saving on Your Part D Premium 

Your Medicare Advantage Plan's premium may include the premium 
for Medicare prescription drug coverage (Part D). Some plans 
may pay all or part of the premium for prescription drug coverage. 
Plans decide each year whether to offer this help, so read the plan 
materials carefully. 

If you have limited income and resources, you may be able to 
get "extra help" paying for your Part D premium and other 
prescription drug coverage costs. See pages 78-81. 



53 



54 



Section 2 — Decide How to Get Your Medicare 



How Do Medicare Advantage Plans Work? 





Preferred Provider Health Maintenance 
Organization (PPO) Plan Organization (HMO) Plan 


Are prescription drugs 
covered? 


In most cases, yes. Ask the plan. 
If you want drug coverage, you 
must join a PPO Plan that offers 
prescription drug coverage. 


In most cases, yes. Ask the plan. If you 
want drug coverage, you must enroll in 
an HMO Plan that offers prescription 
drug coverage. 


Do 1 need to choose a 
primary care doctor? 


No. 


In most cases, yes. 


Can 1 get my health 
care from any doctor 
or hospital? 


Yes. PPOs have network doctors 
and hospitals, but you can also 
use out-of-network providers for 
covered services, usually for a 
higher cost. 


No. You generally must get your 
care and services from doctors or 
hospitals in the plan's network (except 
emergency care, out-of-area urgent 
care, or out-of-area dialysis). If the 
plan offers Point-of-Service, you can 
go out-of-network for certain services 
for a higher cost. 


Do 1 have to get 
a referral to see a 
specialist? 


No. 


In most cases, yes. Yearly screening 
mammograms and in-network Pap 
tests and pelvic exams (at least every 
other year) don't require a referral. 


What else do 1 need 
to know about this 
type of plan? 


■ There are two types of PPOs — 
Regional PPOs and Local 
PPOs. 

■ Regional PPOs must limit 
your out-of-pocket costs for 
Medicare-covered services. 
This limit varies by plan. 


■ If your doctor leaves the plan, your 
plan will notify you. You can choose 
another doctor in the plan. 

■ If you get health care outside the 
plan's network, you may have to pay 
the full cost. 

■ It's important that you follow 
the plan's rules, like getting prior 
approval when needed. 



Medicare Advantage Plans can vary. Read individual plan materials carefully to make sure you 
understand the plan's rules. You may want to contact the plan to find out if the service you need is 
covered and how much it costs. Visit www.medicare.gov, or call 1-800-MEDICARE (1-800-633-4227) 
to find plans in your area. TTY users should call 1-877-486-2048. 



Section 2 — Decide How to Get Your Medicare 



55 



How Do Medicare Advantage Plans Work? (continued) 





Private Fee-for-Service Medical Savings Account 
(PFFS) Plan (MSA) Plan 


Are prescription drugs 
covered? 


Sometimes. If your PFFS Plan 
doesn't offer drug coverage, you 
can join a Medicare Prescription 
Drug Plan to get coverage. 


No. You can join a Medicare Prescription 
Drug Plan to get drug coverage. 


Do 1 need to choose a 
primary care doctor? 


No. 


No. 


Can 1 get my health 
care from any doctor 
or hospital? 


In most cases, yes. You can go to 
any Medicare-approved doctor 
or hospital if they agree to 
treat you. Not all providers will 
accept the plan's payment terms 
or agree to treat you. 


Yes. Some plans may have preferred 
doctors and hospitals you could go to for 
a lower cost. 


Do 1 have to get 
a referral to see a 
specialist? 


No. 


No. 


What else do 1 need 
to know about this 
type of plan? 


■ PFFS Plans aren't the same as 
Original Medicare or Medigap. 

■ The plan decides how much it 
will pay doctors and hospitals 
and how much you must pay 
for services. 

■ Doctors, hospitals, and other 
providers may decide on a case- 
by-case basis not to treat you. 

■ Before you join a PFFS Plan, 
make sure you find doctors, 
hospitals, and other types of 
providers who agree to treat 
you and accept the PFFS Plan's 
payment terms. 


■ Medicare MSA Plans have two parts: a 
high deductible health plan and a bank 
account. Medicare gives the plan an 
amount each year for your health care, 
and the plan deposits a portion of this 
money into your account. The amount 
deposited is usually less than your 
deductible amount so you will have to 
pay out-of-pocket before your coverage 
begins. 

■ Money spent for Medicare- covered 
Part A and Part B services counts 
toward your plan's deductible. After you 
reach your deductible, your plan will 
cover your Medicare-covered services. 

■ Any money left in your account at the 
end of the year remains in your account 
along with the deposit for next year. 



56 



Section 2 — Decide How to Get Your Medicare 



How Do Medicare Advantage Plans Work? (continued) 





Special Needs Plan 
(SNP) 


Are prescription drugs 
covered? 


Yes. All SNPs must provide Medicare prescription drug coverage (Part D). 


Do 1 need to choose a 
primary care doctor? 


Generally, yes, or you may need to have a care coordinator to help plan 
your care. 


Can 1 get my health 
care from any doctor 
or hospital? 


You generally must get your care and services from doctors or hospitals 
in the plan's network (except emergency care, out-of-area urgent care, or 
out-of-area dialysis). Plans typically have specialists for the diseases or 
conditions that affect their members. 


Do 1 have to get 
a referral to see a 
specialist? 


In most cases, yes. Yearly screening mammograms and an in-network Pap 
test and pelvic exam (at least every other year) don't require a referral. 


What else do 1 need 
to know about this 
type of plan? 


■ SNPs serve people who either 1) live in certain institutions (like a 
nursing home) or who require nursing care at home, or 2) are eligible 
for both Medicare and Medicaid, or 3) have one or more specific chronic 
or disabling conditions (like diabetes, congestive heart failure, a mental 
health condition, or HIV/ AIDS). 

■ A plan may limit plan membership to people in one of these groups 
or further limit membership within these groups. It may also enroll a 
limited number of other people. 

■ Plans should coordinate the services and providers you need to help you 
stay healthy and follow your doctor's orders. 

■ If you have Medicare and Medicaid, make sure that all of the plan 
doctors or other health care providers you use accept Medicaid. 

■ If you live in an institution, make sure that plan doctors or other health 
care providers serve people where you live. 

■ You may be disenrolled if you no longer meet the plan's membership 
requirements, like if you lose Medicaid or leave a nursing home. If you 
are disenrolled, you will be returned to Original Medicare and will have 
3 months to join another Medicare health or prescription drug plan. 



Visit www.medicare.gov, or call 1-800-MEDICARE (1-800-633-4227) to find plans in your area. 
TTY users should call 1-877-486-2048. 



Section 2 — Decide How to Get Your Medicare 



57 







Blue words 
in the text 
are defined 
on pages 
115-118. 



How Do Medicare Advantage Plans Work? 
(continued) 

Can You Join a Medicare Advantage Plan if You Have Employer 
or Union Coverage? 

Talk to your employer or union benefits administrator about 
their rules before you join a Medicare Advantage Plan. In some 
cases, joining a Medicare Advantage Plan might cause you to lose 
employer or union coverage. In other cases, if you join a Medicare 
Advantage Plan, you may still be able to use your employer or 
union coverage along with the plan you join. Remember, if you 
drop your employer or union coverage, you may not be able to get 
it back. 

What Happens if You Drop Your Medigap (Medicare 
Supplement Insurance) Policy When You Join a Medicare 
Advantage Plan? 

■ In most cases, if you drop your Medigap policy, you wont be able 
to get it back. 

■ However, you may have special Medigap protections if this is 
the first time you have done either of the following: 

— Joined a Medicare Advantage Plan or other Medicare health 
plan 

— Bought a Medicare SELECT policy (a Medigap policy that 
requires you to use specific hospitals and, in some cases, 
specific doctors to get full coverage) 

■ These protections give you a right to get your old Medigap policy 
back or buy a new one if you choose to leave your Medicare 
health plan or drop your Medicare SELECT policy within the first 
year. See page 76. In either case, the new Medigap policy can t 
include prescription drug coverage. 

■ However, you may be able to join a Medicare Prescription Drug 
Plan if you join a Medicare Advantage Plan and leave it within the 
first year. 

■ Check with your State Health Insurance Assistance Program 
(SHIP) to see if your state offers other rights to buy Medigap 
policies. See pages 111-114 for the telephone number. 



58 Section 2 — Decide How to Get Your Medicare 

How Do Medicare Advantage Plans Work? 
(continued) 

Special Rules for People with End-Stage Renal Disease (ESRD) 

If you have ESRD (permanent kidney failure requiring dialysis or 
a kidney transplant) and you have Original Medicare, you may 
join a Medicare Prescription Drug Plan. However, you usually 
cant join a Medicare Advantage Plan. 

■ If you are already in a Medicare Advantage Plan when you 
develop ESRD, you can stay in it or join another plan offered by 
the same company under certain circumstances. 

■ If you have an employer or union health plan or other health 
coverage offered by a company that offers Medicare Advantage 
Plans, you may be able to join one of their Medicare Advantage 
Plans. 

■ If you've had a successful kidney transplant, you may be able to 
join a Medicare Advantage Plan. 

If you have ESRD and are in a Medicare Advantage Plan, and the 
plan leaves Medicare or no longer provides coverage in your area, 
you have a one-time right to join another Medicare Advantage 
Plan. You don't have to use your one-time right to join a new 
plan immediately. If you go directly to Original Medicare after 
your plan leaves or stops providing coverage, you will still have a 
one-time right to join a Medicare Advantage Plan later, as long as 
the plan you choose is accepting new members. 

You may also be able to join a Medicare Special Needs Plan (SNP) 
for people with ESRD if one is available in your area. 

For more information about ESRD, visit 
www.medicare.gov/Publications/Pubs/pdf/ 1 1 28.pdf to view 
the booklet "Medicare Coverage of Kidney Dialysis and Kidney 
Transplant Services." 



Section 2 — Decide How to Get Your Medicare 



59 







Blue words 
in the text 
are defined 
on pages 
115-118. 



When Can You Join, Switch, or Drop a Medicare 
Advantage Plan? 

You can join, switch, or drop a Medicare Advantage Plan at these 
times: 

■ When you first become eligible for Medicare (3 months before 
you turn age 65 to 3 months after the month you turn age 65). 

■ If you get Medicare due to a disability, you can join during the 

3 months before to 3 months after your 25th month of disability. 

■ Between November 15-December 31 each year. Your coverage 
will begin on January 1 of the following year. 

■ Between January 1 -March 31 of each year. However, you cant 
join or switch to a plan with prescription drug coverage during 
this time unless you already have Medicare prescription drug 
coverage (Part D). You also cant drop a plan with prescription 
drug coverage or join, switch, or drop a Medicare Medical Savings 
Account Plan during this period. 

In most cases, you must stay enrolled for that calendar year starting 
the date your coverage begins. However, in certain situations, you 
may be able to join, switch, or drop a Medicare Advantage Plan at 
other times. Some of these situations include the following: 

■ If you move out of your plan's service area 

■ If you have both Medicare and Medicaid 

■ If you qualify for "extra help" 

■ If you live in an institution 

You can call your State Health Insurance Assistance Program 
(SHIP) for more information. See pages 111-114 for the telephone 
number. 



What Happens If Your Medicare Advantage 
Plan Leaves Medicare? 

If your plan leaves Medicare, it will send you a letter about your 
options. Generally, you will automatically return to Original 
Medicare if you don't choose to join another Medicare Advantage 
Plan. You will also have the right to buy a Medigap policy. See 
pages 75-76. 



60 Section 2 — Decide How to Get Your Medicare 

How Do You Join a Medicare Advantage Plan? 

Once you choose a Medicare Advantage Plan, you may be able 
to join by completing a paper application, calling the plan, or 
enrolling online. Talk with the plan to find out how you can join. 
When you join a Medicare Advantage Plan, you will have to 
provide your Medicare number and the date your Part A and/or 
Part B coverage started. This information is on your Medicare card. 

How Do You Switch Medicare Advantage Plans? 

If you are already in a Medicare Advantage Plan and want to switch 
during one of the times listed on page 59, this is what you need to do: 

■ To switch to a new Medicare Advantage Plan, simply join the 
plan you choose during a period listed on page 59. You will be 
disenrolled automatically from your old plan when your new 
plan's coverage begins. 

■ To switch to Original Medicare, contact your current plan or call 
1-800-MEDICARE (1-800-633-4227). TTY users should call 
1-877-486-2048. 



Q 



No one should call you or come to your home uninvited to 
sell Medicare products. See pages 94-97 for more information 
about how to protect yourself from identity theft and fraud. 
If you believe a plan has misled you, call 1-800-MEDICARE. 



Section 2 — Decide How to Get Your Medicare 



61 







Blue words 
in the text 
are defined 
on pages 
115-118. 



Other Medicare Health Plans 

Some people who have or are eligible for Medicare get their 
coverage from other types of Medicare health plans, or from other 
government or private insurance. 

Some types of Medicare plans that provide health care coverage 
aren't Medicare Advantage Plans but are still part of Medicare. 
Some of these plans provide Part A (Hospital Insurance) and/or 
Part B (Medical Insurance) coverage, and some also provide Part D 
(Medicare prescription drug coverage). These plans have some of 
the same rules as Medicare Advantage Plans. Some of these rules are 
explained briefly below and on the next page. However, each type 
of plan has special rules and exceptions, so you should contact any 
plans you're interested in to get more details. 

Medicare Cost Plans 

Medicare Cost Plans are a type of Medicare health plan available in 
certain areas of the country. You should know the following about 
Medicare Cost Plans: 

■ You can join even if you only have Part B. 

■ If you go to a non-network provider, the services are covered under 
Original Medicare. You would pay the Part B premium, and the 
Part A and Part B coinsurance and deductibles. 

■ You can join any time the plan is accepting new members. 

■ You can leave any time and return to Original Medicare. 

■ You can either get your Medicare prescription drug coverage from 
the plan (if offered), or you can join a Medicare Prescription Drug 
Plan to add prescription drug coverage. 

There is another type of Medicare Cost Plan that only provides 
coverage for Part B services. These plans never include Part D. Part A 
services are covered through Original Medicare. These plans are 
either sponsored by employer or union group health plans, or offered 
by companies that don't provide Part A services. 

For more information about Medicare Cost Plans, contact the plans 
you're interested in. You can also visit www.medicare.gov. Your State 
Health Insurance Assistance Program (SHIP) can also give you more 
information. See pages 111-114 for the telephone number. 



62 



Section 2 — Decide How to Get Your Medicare 

Other Medicare Health Plans (continued) 

Demonstrations/Pilot Programs 

Demonstrations and pilot programs, sometimes called "research 
studies," are special projects that test improvements in Medicare 
coverage, payment, and quality of care. They usually operate only 
for a limited time for a specific group of people and/or are offered 
only in specific areas. Check with the demonstration or pilot 
program for more information about how it works. 

For more information about current Medicare demonstrations 
and pilot programs, visit www.medicare.gov. You can also call 
1-800-MEDICARE (1-800-633-4227) and say "Agent." TTY users 
should call 1 -877-486-2048. 

Programs of All-inclusive Care for the Elderly (PACE) 

PACE combines medical, social, and long-term care services, and 
prescription drug coverage for frail elderly and disabled people. 
This program provides community-based care and services to 
people who otherwise need nursing home-level of care. 

To qualify for PACE, you must meet the following conditions: 

■ You are age 55 or older. 

■ You live in the service area of a PACE organization. 

■ You are certified by your state as meeting the need for nursing 
home-level care. 

■ At the time you join, you are able to live safely in the community 
with the help of PACE services. 

PACE is only available in states that have chosen it as an optional 
Medicaid benefit. Call your State Medical Assistance (Medicaid) 
office to find out if you are eligible and if there is a PACE site near 
you. For more information, you can also visit 
www.medicare.gov/Publications/Pubs/pdf/11341.pdfto view the 
fact sheet "Quick Facts about Programs of All-inclusive Care for the 
Elderly (PACE)." 

See pages 103-104 for more information about PACE and 
long-term care. 




Section 2 — Decide How to Get Your Medicare 

Medicare Prescription Drug Coverage (Part D) 

Medicare offers prescription drug coverage (Part D) for everyone 
with Medicare. To get Medicare drug coverage, you must join 
a plan run by an insurance company or other private company 
approved by Medicare. Each plan can vary in cost and drugs 
covered. If you want Medicare drug coverage, you need to choose a 
plan that works with your health coverage. 

There are two ways to get Medicare prescription drug coverage: 

1. Medicare Prescription Drug Plans. These plans (sometimes 
called "PDPs") add drug coverage to Original Medicare, some 
Medicare Cost Plans, some Medicare Private Fee-for-Service 
(PFFS) Plans, and Medicare Medical Savings Account (MSA) 
Plans. 

2. Medicare Advantage Plans (like an HMO or PPO) or other 
Medicare health plans that offer Medicare prescription 
drug coverage. You get all of your Part A and Part B coverage, 
including prescription drug coverage (Part D), through these 
plans. Medicare Advantage Plans with prescription drug 
coverage are sometimes called "MA-PDs." 

Both types of plans are called "Medicare drug plans" in this 

_,, . section. 

Blue words 

in the text Even if you don't take a lot of prescription drugs now, you should 

are defined still consider joining a Medicare drug plan. See page 44 for a list of 

on pages things to consider when choosing a plan. If you decide not to join a 

115-118. Medicare drug plan when you are first eligible, and you don't have 

other creditable prescription drug coverage, you will likely pay a 

late enrollment penalty (higher premiums) if you choose to join 

later. See page 68 for more information on creditable coverage. 

Note: Discount cards, doctor samples, free clinics, drug discount 
websites, and manufacturer's pharmacy assistance programs aren't 
prescription drug coverage and aren't creditable coverage. 



63 



O 



If you have limited income and resources, you may qualify for 
"extra help" from Medicare paying for prescription drug coverage. 
You may also be able to get help from your state. See pages 78-81. 



64 



Section 2 — Decide How to Get Your Medicare 



© 



How Do Medicare Drug Plans Work? 

Who Can Get Medicare Drug Coverage? 

To join a Medicare Prescription Drug Plan, you must have Medicare 
Part A and/or Part B. To join a Medicare Advantage Plan (like an 
HMO or PPO), you must have Part A and Part B. You must also live 
in the service area of the Medicare drug plan you want to join. 

If you have employer or union coverage, call your benefits 
administrator before you make any changes, or before you sign 
up for any other coverage. If you drop your employer or union 
coverage, you may not be able to get it back. You also may not 
be able to drop your employer or union drug coverage without 
also dropping your employer or union health (doctor and 
hospital) coverage. If you drop coverage for yourself, you may 
also have to drop coverage for your spouse and dependents. 



Blue words 
in the text 
are defined 
on pages 
115-118. 



Choosing Medicare Prescription Drug Coverage (Part D) 

Joining a Medicare drug plan when you are first eligible means you 
won't have to pay a late enrollment penalty. Every year (between 
November 15-December 31), you can switch to a different Medicare 
drug plan if your plan coverage is changing or your needs change. 
When you join or switch to a new Medicare drug plan, your coverage 
generally begins on January 1 of the following year. See page 68 for 
important information about the late enrollment penalty. 

After you join a Medicare drug plan, the plan will mail you 
membership materials, including a card to use when you get your 
prescriptions filled. When you use the card, you may have to pay a 
copayment, coinsurance, and/or deductible charged by the plan. 

Note: The Medicare drug plan you join will release your personal 
information to Medicare and other plans as necessary for treatment, 
payment, and health care operations. Medicare may release your 
personal information for research and other purposes. See 
pages 92-93 to find out more about how Medicare can use your 
personal information. 




Section 2 — Decide How to Get Your Medicare 

When Can You Join, Switch, or Drop a Medicare 
Drug Plan? 

You can join, switch, or drop a Medicare drug plan at these times: 

■ When you first become eligible for Medicare. 

■ Between November 15-December 31 each year. Your coverage 
will begin on January 1 of the following year. 

In most cases, you must stay enrolled for that calendar year starting 
the date your coverage begins. However, in certain situations, you 
may be able to join, switch, or drop Medicare drug plans during 
a special enrollment period (like if you move out of the service 
area, lose other creditable prescription drug coverage, live in an 
institution, or qualify for "extra help"). 

Call your State Health Insurance Assistance Program (SHIP) for 
more information. See pages 1 1 1-1 14 for the telephone number. 

How Do You Join a Medicare Drug Plan? 

Once you choose a Medicare drug plan, you may be able to join by 
completing a paper application, calling the plan, or enrolling online. 
Medicare drug plans aren't allowed to call you to enroll you in a 
plan. See pages 94-97 for more information about how to protect 
yourself from fraud. 

Contact the plan to find out how you can join. When you join 
a Medicare drug plan, you will have to provide your Medicare 
number and the date your Part A or Part B coverage started. This 
information is on your Medicare card. Visit www.medicare.gov, or 
call 1-800-MEDICARE (1-800-633-4227) for a list of the Medicare 
plans in your area. TTY users should call 1-877-486-2048. 

How Do You Switch Your Medicare Drug Plan? 

Depending on your circumstances, you can switch to a new 
Medicare drug plan simply by joining another drug plan during 
one of the times listed above. You don't need to cancel your old 
Medicare drug plan or send them anything. Your old Medicare 
drug plan coverage will end when your new drug plan begins. You 
should get a letter from your new Medicare drug plan telling you 
when your coverage begins. 



65 



66 



Section 2 — Decide How to Get Your Medicare 




Blue words 
in the text 
are defined 
on pages 
115-118. 




How Much Does Medicare Drug Coverage Cost? 

Exact coverage and costs are different for each plan, but all 
Medicare drug plans must provide at least a standard level of 
coverage set by Medicare. 

Below and continued on page 67 are descriptions of the payments 
you make throughout the year in a Medicare drug plan. After the 
descriptions is an example of what someone may pay in a plan. 
Your actual drug plan costs will vary depending on the drugs you 
use, the plan you choose, whether you go to a pharmacy in your 
plan's network, and whether you qualify for "extra help" paying 
your Part D costs. 

■ Monthly premium — Most drug plans charge a monthly fee that 
varies by plan. You pay this in addition to the Part B premium. If 
you belong to a Medicare Advantage Plan (like an HMO or PPO) 
or a Medicare Cost Plan that includes Medicare prescription 
drug coverage, the monthly premium may include an amount for 
prescription drug coverage. 

■ Yearly deductible — Amount you pay for your prescriptions 
before your plan begins to pay. Some drug plans charge no 
deductible. 

■ Copayments or coinsurance — Amounts you pay for your 
prescriptions after the deductible. You pay your share, and your 
plan pays its share for covered drugs. 

■ Coverage gap — Most Medicare drug plans have a coverage gap. 
This means that after you and your plan have spent a certain 
amount of money for covered drugs, you have to pay all costs 
out-of-pocket for your drugs up to a limit. Your yearly deductible, 
your coinsurance or copayments, and what you pay in the 
coverage gap all count toward this out-of-pocket limit. The limit 
doesn't include the drug plan's premium. 

There are plans that offer some coverage during the gap, like for 
generic drugs. However, plans with gap coverage may charge a 
higher monthly premium. Check with the plan first to see if your 
drugs would be covered during the gap. 



Section 2 — Decide How to Get Your Medicare 



67 



How Much Does Medicare Drug Coverage Cost? 
(continued) 

■ Catastrophic coverage— Once you reach your plans out-of-pocket 
limit during the coverage gap, you automatically get "catastrophic 
coverage." Catastrophic coverage assures that once you have spent 
up to your plan's out-of-pocket limit for covered drugs, you only 
pay a small coinsurance amount or a copayment for the rest of the 
year. 

Note: If you get "extra help" paying your drug costs, you won't 
have a coverage gap and will pay a small or no copayment once you 
reach catastrophic coverage. See pages 78-81. 

The example below shows the costs for covered drugs in 2009 for a 
plan that has a coverage gap. 



Ms. Smith joins the ABC Prescription Drug Plan. Her coverage begins on 
January 1, 2009. She doesn't get "extra help" and uses her Medicare drug plan 
membership card when she buys prescriptions. 






Monthly Premium — Ms. Smith pays a monthly premium throughout the ye; 



1. Yearly 
Deductible 



Ms. Smith pays 
the first $295 of 
her drug costs 
before her plan 
starts to pay its 
share. 



ipaym 
Coinsurano 



Ms. Smith pays a 
copayment, and her 
plan pays its share 
for each covered 
drug until what 
they pay (plus the 
deductible) reaches 
$2,700. 



Once Ms. Smith 
and her plan have 
spent $2,700 for 
covered drugs, she 
is in the coverage 
gap. She will have 
to pay all of her 
drug costs until she 
has spent $4,350. 



►verage 



Once Ms. Smith 
has spent $4,350 
out-of-pocket for the 
year, her coverage 
gap ends. Now she 
only pays a small 
copayment (like $6) 
for each drug until 
the end of the year. 



O 



Call the plans you're interested in to get specific Medicare drug plan costs. 
You can also visit www.medicare.gov, or call 1-800-MEDICARE 
(1-800-633-4227). TTY users should call 1-877-486-2048. 



68 Section 2 — Decide How to Get Your Medicare 

What is the Part D Late Enrollment Penalty? 

The late enrollment penalty is an amount that is added to your 
Part D premium (for as long as you have Medicare drug coverage) 
if all of the following are true: 

■ You don't join a Medicare drug plan when you're first eligible. 

■ You don't have other creditable prescription drug coverage. 

■ You later decide to join a Medicare drug plan. 

Here are a Few Ways to Avoid Paying a Penalty: 

■ Join a Medicare drug plan when you're first eligible. You won't 
have to pay a penalty, even if you've never had prescription drug 
coverage before. 

■ Don't go for more than 63 days without a Medicare drug plan 
or other creditable coverage. Creditable coverage could include 

Blue words drug coverage from a former employer or union, TRICARE, or 

in the text fae Department of Veterans Affairs. (You should get a notice 

are defined every year telling you whether the drug coverage you have is 

0n P a 9 es creditable coverage. Keep this notice, because you may need it if 

115-118. y OU j j n a Medicare drug plan later.) 

■ Let your Medicare drug plan know if you have other creditable 
coverage. Watch carefully for a letter from your plan asking if you 
have creditable coverage and complete the form they give you if 
you do. If you don't tell the plan about your creditable coverage, 
you may have to pay a penalty. 

How Much Will Your Part D Late Enrollment 
Penalty Be? 

When you join a Medicare drug plan, the plan will tell you if you 
owe a penalty, and what your premium will be. To estimate your 
penalty amount, count the number of full months that you didn't 
have creditable coverage after you were eligible to join a Medicare 
drug plan. If you multiply this number by $.30 (the "1% penalty 
calculation" number on page 122), you can estimate the amount 
that will be added each month to your Medicare drug plan's 
premium for the current year. This penalty amount may increase 
every year. 



o 



Section 2 — Decide How to Get Your Medicare 

Important Drug Coverage Rules 

The following information can help answer common questions as 
you begin to use your coverage. 

What If You Need to Fill a Prescription Before You Get Your 
Medicare Drug Plan Membership Card? 

About a week after you join a plan, you will get a letter from the plan 
letting you know they got your information. Three to 5 weeks later, 
you should get a welcome package with your membership card. 
If you need to go to the pharmacy before your membership card 
arrives, you can use any of the following as proof of membership in 
your Medicare drug plan: 

■ A letter from the plan 

■ An enrollment confirmation number that you got from the plan, 
the plan name, and telephone number 

You should also bring your Medicare and/or Medicaid card, proof 
of any other prescription drug coverage, and a photo ID. If you 
qualify for "extra help," see page 81 for more information about 
what you can use as proof of "extra help." If you don't have any of 
the items listed above, and your pharmacist can't get your drug plan 
information any other way, you may have to pay out-of-pocket for 
your prescriptions. If you do, save the receipts and contact your 
plan to get money back. 

If you want to know how Medicare prescription drug coverage 
works with other drug coverage you may have, see pages 72-73. 

Enroll early in the month to give the plan time to mail your 
membership card, acknowledgement letter, and welcome 
package before your coverage becomes effective. This way, 
even if you go to the pharmacy on your first day of coverage, 
you can get your prescriptions filled without delay. 



69 



70 Section 2 — Decide How to Get Your Medicare 



Important Drug Coverage Rules (continued) 

Plans may have the following coverage rules: 

■ Prior authorization — You and/or your doctor must contact the 
plan before you can fill certain prescriptions. Your doctor may 
need to show that the drug is medically necessary for it to be 
covered. 

■ Quantity limits — Limits how many pills you can get at a time. 



Blue words 

■ Step therapy — You must try one or more similar, lower cost drugs 

before the plan will cover the drug your doctor prescribed, 
on pages ° ' r 

115-118. If your doctor believes that one of these coverage rules should be 

waived, you can ask for an exception. See pages 90-91. 

What Are "Tiers" or "Categories" on a Medicare Drug Plan's 
Formulary? 

Many Medicare drug plans place drugs into different "tiers." Drugs 
in each tier have a different cost. For example, a drug in a lower tier 
will cost you less than a drug in a higher tier. In some cases, if your 
drug is on a higher tier and your doctor thinks you need that drug 
instead of a similar drug on a lower tier, you can file an exception 
and ask your plan for a lower copayment. See pages 90-91. 

Note: Information about a plans list of covered drugs (called a 
formulary) isn't included in this handbook because each plan has 
its own formulary. Formularies can change. Contact the plan for its 
current formulary, or visit the plan's website. 



O 



In most cases the prescription drugs you get in an outpatient 
setting like an emergency room aren't covered by Part B. Your 
Medicare drug plan may cover these drugs under certain 
circumstances. You will likely need to pay out-of-pocket for 
these drugs and submit a claim to your plan. Call your plan for 
more information. 



Section 2 — Decide How to Get Your Medicare 



71 




Important Drug Coverage Rules (continued) 

What Are the Ways to Pay Your Medicare Drug Plan Premium? 

You have choices in the way you pay your Medicare drug plan 
premium. Depending on your plan and your situation, you may be 
able to pay your Medicare drug plan premium in one of four ways: 

1. Deducted from your checking or savings account. 

2. Charged to a credit or debit card. 

3. Billed to you each month directly by the plan. (Some plans bill 
in advance for coverage the next month.) 

4. Deducted from your Social Security payment. Contact your 
plan (not Social Security) to ask for this payment option. With 
this option, your first deductions usually take 2 months to start, 
and 2 months of premiums will likely be collected at one time. 

For more information about your Medicare drug plan premium 
or ways to pay for it, contact your plan. 

Use the following resources to get more information about 
Medicare prescription drug coverage: 

■ Contact the plans you are interested in. 

■ Visit www.medicare.gov/pdphome.asp to get general information, 
view publications, and find plans in your area. 

■ Call 1-800-MEDICARE (1-800-633-4227) and say, "Drug 
Coverage." TTY users should call 1-877-486-2048. 



72 



Section 2 — Decide How to Get Your Medicare 



Other Private Insurance 

The charts on the next two pages provide information about how other 
insurance you have works with, or is affected by, Medicare prescription drug 
coverage (Part D). 



Employer or Union Health Coverage — Health coverage from your, your 
spouse's, or other family members current or former employer or union. If you 
have prescription drug coverage based on your current or previous employment, 
your employer or union will notify you each year to let you know if your drug 
coverage is creditable. Keep the notices you get. Call your benefits administrator 
for more information. 



COBRA — A Federal statute that may allow you to temporarily keep employer 
or union health coverage after the employment ends or after you lose coverage 
as a dependent of the covered employee. As explained on page 24, there may 
be reasons why you should take Part B instead of COBRA. However, if you 
take COBRA and it includes creditable prescription drug coverage, you will 
have a special enrollment period to join a Medicare drug plan without paying a 
penally when the COBRA coverage ends. Talk with your State Health Insurance 
Assistance Program (SHIP) to see if COBRA is a good choice for you. See 
pages 1 1 1-1 14 for the telephone number. 



Medigap (Medicare Supplement Insurance) Policy with Prescription Drug 
Coverage — If you have prescription drug coverage under a current Medigap 
policy, the issuer of the policy will notify you each year to let you know if 
the coverage is creditable. Most Medigap coverage isn't creditable. You can't 
join a Medicare drug plan and keep the prescription drug coverage in your 
Medigap policy. If you join, your Medigap insurance company must remove 
the prescription drug coverage under your Medigap policy and reduce your 
premiums. Call your Medigap insurance company for more information. 



Note: Keep any creditable coverage notice you get. You may need it if you 
decide to join a Medicare drug plan later. 



Section 2 — Decide How to Get Your Medicare 

Other Government Insurance 



Federal Employee Health Benefits Program (FEHBP) — Health coverage for 
current and retired Federal employees and covered family members. Prescription 
drug coverage under FEHBP is considered creditable, and, in most cases, it will 
be to your advantage to keep your current coverage. If you join a Medicare drug 
plan, you can keep your FEHBP plan, and your plans will let you know who 
pays first. For more information, contact the Office of Personnel Management 
at 1-888-767-6738, or visit www.opm.gov/insure. TTY users should call 
1-800-878-5707. You can also call your plan if you have questions. 



Veterans Benefits — Health coverage for veterans and people who have served in 
the U.S. military. You may be able to get prescription drug coverage through the 
VA program. This coverage is considered creditable. You may join a Medicare 
drug plan, but if you do, you can't use both types of coverage at the same time. 
In most cases, it will be to your advantage to keep your current coverage. 
For more information, call the U.S. Department of Veterans Affairs (VA) at 
1-800-827-1000, or visit www.va.gov. TTY users should call 1-800-829-4833. 



Military Benefits (TRICARE) — Health care program for active-duty service 
members, retirees, and their families. All people with TRICARE are eligible 
for TRICARE pharmacy benefits. Most people keep their TRICARE pharmacy 
benefits because they are considered creditable prescription drug coverage. You 
may also add Medicare prescription drug coverage. If you do, your Medicare 
drug plan pays first and TRICARE pays second. In most cases, it will be to 
your advantage to keep your current coverage. For more information, call the 
contractor that handles TRICARE claims at 1-866-773-0404, or visit 
www.tricare.osd.mil. TTY users should call 1-866-773-0405. 



Indian Health Services — Health care for people who are American Indian/ 
Alaska Native through an Indian health care provider. If you get health care from 
one of these providers, you have creditable prescription drug coverage. If you 
get prescription drugs through an Indian health pharmacy, you pay nothing and 
your coverage won't be interrupted. Joining a Medicare drug plan may help your 
Indian health provider with costs, because the drug plan pays part of the cost of 
your prescriptions. For more information, contact your local health care provider 
to find out how Medicare works with your health care system. 



74 Section 2 — Decide How to Get Your Medicare 

How Your Bills Get Paid If You Have Other 
Health Insurance 

When you have other insurance, there are rules that decide 
whether Medicare or your other insurance pays first. The 
insurance that pays first is called the "primary payer" and pays 
up to the limits of its coverage. The one that pays second, called 
the "secondary payer," only pays if it covers any of the costs left 
uncovered by the primary coverage. 

If your other coverage is from an employer or union group health 
plan, these rules apply: 

■ If you are retired, Medicare pays first. 

■ If your coverage is based on your or a family members current 
employment, who pays first depends on your age, the size of the 
employer, and whether you have Medicare based on age, disability, 
or ESRD: 

— If you are under age 65 and disabled, your plan pays first if 
your employer has 100 or more employees. 

— If you are over age 65 and still working, your plan pays first 
if your employer has 20 or more employees. 

■ If you have Medicare because you have ESRD, in all cases your 
plan pays first for the first 30 months you have Medicare. 

The following types of coverage always pay first: 

■ No-fault insurance (including automobile insurance) 

■ Liability (including automobile insurance) 

■ Black lung benefits 

■ Workers' compensation 



O 



If you have other insurance, tell your doctor, hospital, 
and pharmacy so your bills get paid correctly. If you have 
questions about who pays first, or you need to update your 
other insurance information, call Medicare's Coordination 
of Benefits Contractor at 1-800-999-1118. TTY users should 
call 1-800-318-8782. 



Section 2 — Decide How to Get Your Medicare 



75 




Blue words 
in the text 
are defined 
on pages 
115-118. 



Medigap (Medicare Supplement Insurance) 
Policies 

Original Medicare pays for many, but not all, health care services 
and supplies. A Medigap policy, sold by private insurance 
companies, can help pay some of the health care costs ("gaps") that 
Original Medicare doesn't cover, like copayments, coinsurance, 
and deductibles. Some Medigap policies also offer coverage for 
services that Medicare doesn't cover, like medical care when 
you travel outside the U.S. If you have Original Medicare and 
you buy a Medigap policy, both plans will pay their share of 
Medicare-approved amounts for covered health care costs. Medicare 
doesn't pay any of the costs for a Medigap policy. 

Every Medigap policy must follow Federal and state laws designed 
to protect you, and it must be clearly identified as "Medicare 
Supplement Insurance." Medigap insurance companies can sell you 
only a "standardized" Medigap policy identified in most states by 
letters (A through L). Each standardized Medigap policy must offer 
the same basic coverage, no matter which insurance company sells 
it. Cost is usually the only difference between Medigap policies sold 
by different insurance companies. 

In Massachusetts, Minnesota, and Wisconsin, Medigap policies are 
standardized in a different way. In some states, you may be able to 
buy another type of Medigap policy called Medicare SELECT (a 
Medigap policy that requires you to use specific hospitals and, in 
some cases, specific doctors to get full coverage). 

What Do You Need to Know If You Want to Buy a 
Medigap Policy? 

■ Generally, you must have Parts A and B to buy a Medigap policy 

■ You pay a monthly premium for your Medigap policy to the private 
insurer, and you pay your monthly Part B premium. See page 119. 

■ A Medigap policy only covers one person. If you and your spouse 
both want Medigap coverage, you each must buy separate Medigap 
policies. 

■ It's important to compare Medigap policies since the costs can vary 
and may go up as you get older. (Prices may be limited by state law) 



76 Section 2 — Decide How to Get Your Medicare 

What Do You Need to Know If You Want to Buy 
a Medigap Policy? (continued) 

■ The best time to buy a Medigap policy is during the 6-month 
period that begins on the first day of the month in which you are 
both age 65 or older and enrolled in Part B. (Some states have 
additional open enrollment periods.) After this initial enrollment 
period, your option to buy a Medigap policy may be limited. 

■ If you are under age 65, you may have additional rights to buy a 
Medigap policy, depending on the laws in your state. 

■ If you have a Medigap policy and join a Medicare Advantage Plan 
(like an HMO or PPO), your Medigap policy can't be used to pay 
your Medicare Advantage Plan copayments and deductibles. 

blue words m jf y OU already have a Medicare Advantage Plan, it's illegal for 

in the text anyone to sell you a Medigap policy unless you are switching 

are defined back t0 Original Medicare. 

■ If you join a Medicare Advantage Plan for the first time, and 
115—118 

you aren't happy with the plan, you have the right to return to 

Original Medicare within the first 12 months of joining. If you 
joined when you were first eligible for Medicare, you can choose 
from any Medigap policy. If you had a Medigap policy before, 
you can get the same plan back (without any prescription drug 
coverage) if the company still sells it. 

■ You can't have drug coverage in both your Medigap policy and a 
Medicare drug plan. See page 72. 

For more information about Medigap policies, visit 
www.medicare.gov/Publications/Pubs/pdf/021 10.pdf to view the 
booklet "Choosing a Medigap Policy: A Guide to Health Insurance 
for People with Medicare." You can also call your State Insurance 
Department to get more information. Call 1-800-MEDICARE 
(1-800-633-4227) to get the telephone number. TTY users should 
call 1-877-486-2048. 

To find Medigap policies, visit www.medicare.gov and select, 
"Compare Medicare Health Plans and Medigap Policies in Your 
Area." You can also call 1-800-MEDICARE or your State Health 
Insurance Assistance Program (SHIP). See pages 111-114 for the 
telephone number. 



Programs for 
People with 
Limited Income 
and Resources 




Q 



There are Federal and state programs available for people with limited 
income and resources. These programs may help you save on your 
health care and prescription drug costs or provide extra income. 

Section 3 includes information about the following: 

"Extra Help" Paying for Medicare Prescription 

Drug Coverage (Part D) 78-81 

Medicaid 82 

State Pharmacy Assistance Programs (SPAPs) 82 

Programs of All- Inclusive Care for the Elderly (PACE) 82 

Medicare Savings Programs 83 

Supplemental Security Income (SSI) Benefits 84 

Programs for People Who Live in the U.S. Territories of 
Puerto Rico, the Virgin Islands, Guam, the Northern 
Mariana Islands, and American Samoa 84 

Keep all information you get from Medicare, Social Security, 
your Medicare health or prescription drug plan, Medigap policy, 
or employer or union. This may include a notice of award 
or denial, an Annual Notice of Change, notice of creditable 
prescription drug coverage, or a Medicare Summary Notice. You 
may need these documents to apply for the programs explained 
in this section. Also keep copies of any applications you submit. 



78 



Section 3 — Programs for People with Limited Incomes and Resources 



Help for People with Limited Income and Resources 

If you have limited income and resources, you might qualify for help to 
pay for some health care and prescription drug costs. 

The U.S. Virgin Islands, Guam, American Samoa, the Commonwealth 
of Puerto Rico, and the Commonwealth of Northern Mariana Islands 
provide their residents help with Medicare drug costs. This help isn't 
the same as the "extra help" described below. See page 84 for more 
information. 



Blue words 
in the text 
are defined 
on pages 
115-118. 



"Extra Help" Paying for Medicare Prescription 
Drug Coverage (Part D) 

What is this program? 

You may qualify for "extra help" (also called the low- income subsidy) 
from Medicare to pay prescription drug costs if your yearly income and 
resources are below the following limits in 2008: 

■ Income less than $15,600 and resources less than $11,990 — Single 
person 

■ Income less than $21,000 and resources less than $23,970 — Married 
person living with a spouse and no other dependents 

These amounts will change in 2009. You may qualify if you have a 
higher income (like if you still work or if you live in Alaska or Hawaii). 
Resources include money in a checking or savings account, stocks, and 
bonds. Resources don't include your home, car, burial plot, up to $1,500 
for burial expenses (per person), furniture, or other household items. 

If you qualify for "extra help" in 2009, and you join a Medicare drug 
plan, you will get the following: 

■ Help paying your Medicare drug plan's monthly premium. Depending 
on your income and resources and your plan's premium, you may pay 
a reduced premium or no premium for a basic plan. For an enhanced 
plan (a plan that may cover more drugs and generally has a higher 
monthly premium), you must pay more for the extra coverage. 

■ Help paying any yearly deductible. 

■ Help paying coinsurance and copayments for prescription drugs that 
are on your plan's formulary (list of covered drugs). You generally pay 
all costs for drugs that aren't on your plan's formulary. 

■ No coverage gap. See pages 66-67. 



Section 3 — Programs for People with Limited Incomes and Resources 



79 



O 



"Extra Help" Paying for Medicare Prescription Drug 
Coverage (Part D) (continued) 

You automatically qualify for "extra help" if you have Medicare and 
meet one of these conditions: 

■ You have full Medicaid coverage. See page 82. 

■ You get help from your state Medicaid program paying your Part B 
premiums (belong to a Medicare Savings Program). See page 83. 

■ You get Supplemental Security Income (SSI) benefits. See page 84. 

What happens if you automatically qualify for "extra help?" 

Medicare will mail you a purple letter to let you know you automatically 
qualify for "extra help." You don't need to apply for "extra help" if you get 
this letter. 

■ Keep the letter for your records. 

■ If you aren't already in a plan, you must join a Medicare drug plan to get 
this "extra help." 

■ If you don't join a drug plan, Medicare will enroll you in one. If Medicare 
enrolls you in a plan, Medicare will send you a yellow or green letter 
letting you know when your coverage begins. 

■ Different plans cover different drugs. Check to see if the plan you are 
enrolled in covers the drugs you use and if you can go to the pharmacies 
you want. Compare with other plans in your area. 

■ You can switch to another Medicare drug plan at any time. Your coverage 
will be effective the first day of the next month. 

■ In most cases, you will pay only a small amount for each covered 
prescription. 

■ If you have Medicaid, Medicare will provide you with prescription drug 
coverage instead of Medicaid. However, some drugs that aren't covered 
by Medicare prescription drug coverage may still be covered by Medicaid. 
Medicaid may still cover other care that Medicare doesn't cover. 

■ If you have Medicaid and live in certain institutions (like a nursing 
home or long-term care hospital), you may pay nothing for your covered 
prescription drugs. 

The exact amount you pay depends on the level of "extra help" 
you get. Look on the "extra help" letters you get, or contact your 
plan to find out your exact premium, deductible, and coinsurance 
or copayment amounts. 



80 -Programs for People with Limited Incomes and Resources 



// 



Extra Help" Paying for Medicare Prescription 
Drug Coverage (Part D) (continued) 

If you don't want to join a Medicare drug plan (for example, 
because you want to keep your employer or union coverage 
instead), call 1-800 -MEDIC ARE (1-800-633-4227) or the plan 
listed in your letter. TTY users should call 1-877-486-2048. Tell 
them you don't want to be in a Medicare drug plan (you want to 
"opt out"). If you continue to qualify for "extra help," you won't have 
to pay a penalty if you join later. See page 68. 

If you didn't automatically qualify for "extra help," you can apply: 

■ Call Social Security at 1-800-772-1213 to apply by phone or to get 
a paper application. TTY users should call 1-800-325-0778. 

■ Visit www.socialsecurity.gov to apply online. 

. ■ ■ Apply at your State Medical Assistance (Medicaid) office. Call 

, , , 1-800-MEDICARE and say "Medicaid" to get their telephone 

are defined , . . ,. 

number, or visit www.medicare.eov. 
on pages & 

115-118. To get answers to your questions about "extra help" paying for your 

prescription drug costs, call your State Health Insurance Assistance 

Program (SHIP). See pages 1 1 1-1 14 for the telephone number. 

If you apply and qualify for "extra help," you must join a 
Medicare drug plan to get this "extra help." If you don't join a 
drug plan, Medicare will enroll you in one. If Medicare enrolls 
you in a plan, Medicare will send you a green letter letting you 
know when your coverage begins. Check to see if the plan you 
are enrolled in covers the drugs you use and if you can go to the 
pharmacies you want. If not, you can switch plans at any time. 



O 



If you have employer or union coverage and you join a Medicare 
drug plan, you may lose your employer or union coverage even 
if you qualify for "extra help." Call your employer's benefits 
administrator for more information before you join. 

Medicare gets data from your state or Social Security that tells 
whether you qualify for "extra help." If Medicare doesn't have the 
right information, you may be paying the wrong amount for your 
prescription drug coverage. 



Section 3 — Programs for People with Limited Incomes and Resources 



81 



// 



Extra Help" Paying for Medicare Prescription 
Drug Coverage (Part D) (continued) 

If you think you qualify for "extra help," what can you do to make 
sure you pay the right amount? 

If you automatically qualify, you should have received a purple, 
yellow, or green letter from Medicare you can show to your plan as 
proof that you qualify. If you applied for "extra help," you can show 
your "Notice of Award" from Social Security as proof that you qualify. 

You can also give your plan any of the following documents as proof 
that you qualify for "extra help." Each item listed below must show 
that you were eligible for Medicaid during a month after June of 2008. 



Other Proof You Have Medicaid 


Proof You Have Medicaid and 




Live in an Institution 


■ A copy of your Medicaid card 


■ A bill from the institution (like 


■ A copy of a state document that 


a nursing home) or a copy of a 


shows you have Medicaid 


state document showing Medicaid 


■ A print-out from a state electronic 


payment to the institution for at 


enrollment file or screen print from 


least a month 


your states Medicaid systems that 


■ A screen print from your states 


shows you have Medicaid 


Medicaid systems showing that you 


■ Any other document from your 


lived in the institution for at least a 


state that shows you have Medicaid 


month 



Call your plan to find out how you can provide them with this 
information. If you think you qualify for "extra help" because you 
have Medicaid, but you don't have proof, ask your plan for help. 

If you paid for prescriptions since you qualified for "extra help," you 
may be able to get back some of these costs. Keep the receipts, and 
call your plan for more information. 

If your plan doesn't correct a problem to help you pay the right 
amount for your prescriptions, you can file a complaint with your 
plan. You can also call 1-800-MEDICARE (1-800-633-4227) to file a 
complaint. TTY users should call 1-877-486-2048. 



82 Section 3 — Programs for People with Limited Incomes and Resources 

Medicaid 

Medicaid is a joint Federal and state program that helps pay medical 
costs if you have limited income and resources. Some people qualify 
for both Medicare and Medicaid (these people are also called 
"dual-eligibles"). 

■ If you have Medicare and full Medicaid coverage, most of your 
health care costs are covered whether you have Original Medicare 
or are in a Medicare Advantage Plan (like an HMO or PPO). 

■ Medicaid programs vary from state to state. They may also be called 
by different names, such as "Medical Assistance" or "Medi-Cal." 

■ People with Medicaid may get coverage for services that aren't fully 
covered by Medicare, such as nursing home and home health care. 

■ Each state may have different Medicaid eligibility income and 
resource limits. 

Blue words ■ In some states, you may need Medicare to be eligible for Medicaid, 

in the text ■ Call your State Medical Assistance (Medicaid) office for more 

are defined information and to see if you qualify. Call 1-800-MEDICARE 

on pages (1-800-633-4227) and say "Medicaid" to get the telephone number 

115-118. for your State Medical Assistance office. TTY users should call 

1-877-486-2048. You can also visit www.medicare.gov. 

State Pharmacy Assistance Programs (SPAPs) 

Many states have State Pharmacy Assistance Programs (SPAPs) that 
help certain people pay for prescription drugs based on financial 
need, age, or medical condition. Each SPAP makes its own rules 
about how to provide drug coverage to its members. Depending on 
your state, the SPAP will help you in different ways. To find out about 
the SPAP in your state, call your State Health Insurance Assistance 
Program (SHIP). See pages 1 1 1-1 14 for the telephone number. 

Programs of All-inclusive Care for the Elderly 
(PACE) 

PACE combines medical, social, and long-term care services, and 
prescription drug coverage for frail elderly and disabled people. This 
program allows people who need nursing home-level care to remain 
in the community. See pages 103-104 for more information. 




Section 3 — Programs for People with Limited Incomes and Resources 

Medicare Savings Programs (Help from 
Medicaid to Pay Medicare Premiums) 

States have programs that pay Medicare premiums and, in some 
cases, may also pay Part A and Part B deductibles and coinsurance. 
These programs help people with Medicare save money each year. 

To qualify for a Medicare Savings Program, you must meet all of 
these conditions: 

■ Have Part A. 

■ Have monthly income less than $1,190 and resources less than 
$4,000 — Single person. 

■ Have monthly income less than $1,595 and resources less than 
$6,000 — Married and living together. 

Note: These amounts may change each year. If you live in Alaska or 
Hawaii, income limits are slightly higher. Many states figure your 
income and resources differently, so you may be eligible in your 
state even if your income is higher. Resources include money in a 
checking or savings account, stocks, and bonds. Resources don't 
include your home, car, burial plot, up to $1,500 for burial expenses 
(per person), furniture, or other household items. 

For More Information 

■ Call or visit your State Medical Assistance (Medicaid) office for 
more information. The names of these programs may vary by state, 
so ask for information on Medicare Savings Programs. Call if you 
think you qualify for any of these programs, even if you aren't sure. 

■ Visit www.medicare.gov/Publications/Pubs/pdf/10126.pdfto view 
the brochure "If You Need Help Paying Medicare Costs, There Are 
Programs That Can Help You." 

■ Call 1-800-MEDICARE (1-800-633-4227), and say "Medicaid" 
to get the telephone number for your state. TTY users should call 
1-877-486-2048. 

■ Contact your State Health Insurance Assistance Program (SHIP) 
for free health insurance counseling. See pages 1 1 1-1 14 for the 
telephone number. 



83 



84 Section 3 — Programs for People with Limited Incomes and Resources 

Supplemental Security Income (SSI) Benefits 

SSI is a monthly amount paid by Social Security to people with 
limited income and resources who are disabled, blind, or age 65 
or older. SSI benefits provide cash to meet basic needs for food, 
clothing, and shelter. SSI benefits aren't the same as Social Security 
benefits. 

To get SSI benefits, you must also meet these conditions: 

■ Be a resident of the U.S. or the Northern Mariana Islands. 

■ Not be out of the country for a full calendar month or more than 30 
consecutive days. 

■ Be either a U.S. citizen or national, or in one of certain categories 
of eligible non-citizens. People who live in Puerto Rico, the Virgin 

Blue words Islands, Guam, or American Samoa generally can't get SSI. You 

in the text can visit www.socialsecurity.gov and use the "Benefit Eligibility 

are defined Screening Tool" to find out if you may be eligible for SSI or other 

on pages benefits. Call Social Security at 1-800-772-1213, or contact your 

115-118. local Social Security office for more information. TTY users should 

call 1-800-325-0778. 

Programs for People Who Live in the U.S. 
Territories of Puerto Rico, the Virgin Islands, 
Guam, the Northern Mariana Islands, and 
American Samoa 

There are programs in Puerto Rico, the Virgin Islands, Guam, the 
Northern Mariana Islands, and American Samoa to help people with 
limited income and resources pay their Medicare costs. Programs 
vary in these areas. Call your local Medical Assistance (Medicaid) 
office to find out more about their rules, or call 1-800-MEDICARE 
(1-800-633-4227) and say "Medicaid" for more information. TTY 
users should call 1-877-486-2048. You can also visit 
www.medicare.gov. 







Free or low cost health insurance is available in your state for 
uninsured children under age 19. Call 1-877-KIDS-NOW 
(1-877-543-7669) for more information about the State Children's 
Health Insurance Program. 



SECTION 4 



85 













You can protect yourself and Medicare by understanding your 
rights (including your right to appeal) and knowing how to 
identify and report fraud. 

Section 4 includes information about the following: 

Medicare Rights and Appeals Information 86-88 

Advance Beneficiary Notices (ABNs) 89 

Appeals (Medicare Drug Plans) 90-91 

How Medicare Uses Your Personal Information 92-93 

Protecting Yourself From Fraud and Identity Theft 94-95 

Senior Medicare Patrol (SMP) 95 

Billing Fraud 96-97 

How Medicare Protects You 97 

Medicare's Beneficiary Ombudsman 98 



86 



Section 4 — Protecting Yourself and Medicare 




Your Medicare Rights 

No matter what type of Medicare coverage you have, you have 
certain guaranteed rights. As a person with Medicare, you have the 
right to all of the following: 

■ Be treated with dignity and respect at all times 

■ Be protected from discrimination 

■ Access to doctors, specialists, and hospitals 

■ Have your questions about Medicare answered 

■ Learn about all of your treatment choices and participate in 
treatment decisions 

■ Get information in a way you understand from Medicare, its 
providers, and contractors under certain circumstances 

■ Get emergency care when and where you need it 

■ Get a decision about health care payment or services, or 
prescription drug coverage 

■ Get a review of (appeal) certain decisions about health care 
payment, coverage of services, or prescription drug coverage 

■ File complaints (sometimes called grievances), including 
complaints about the quality of your care 

■ Have your personal and health information kept private 

What Is an Appeal? 

An appeal is the action you can take if you disagree with a coverage 
or payment decision made by Medicare or your Medicare plan. You 
can appeal if Medicare or your plan denies one of the following: 

■ A request for a health care service, supply, or prescription that 
you think you should be able to get 

■ A request for payment for health care or a prescription drug you 
already got 

■ A request to change the amount you must pay for a prescription 
drug 

You can also appeal if Medicare or your plan stops paying for an 
item or service you think you still need. 

If you decide to file an appeal, ask your doctor, health care provider, 
or supplier for any information that may help your case. 



Section 4 — Protecting Yourself and Medicare 



87 



How to File an Appeal 

How you file an appeal depends on the type of Medicare coverage you have: 

■ If you have a Medicare Advantage Plan or a Medicare Prescription Drug 
Plan, look at your plan materials, call your plan, or visit 
www.medicare.gov to learn how to file an appeal. 

■ If you have Original Medicare, you can file an appeal by following the 
instructions below: 

1. Get the Medicare Summary Notice (MSN) that shows the item 
or service you are appealing. Your MSN is the statement you get 
every 3 months that lists all the services billed to Medicare and 
tells you if Medicare paid for the services. 

2. Circle the item(s) on the MSN you disagree with, and write an 
explanation on the MSN of why you disagree. 

3. Sign, write your telephone number, and provide your Medicare 
number on the MSN. You may want to make a copy to keep for 
your records. 

4. Send the MSN, or a copy, to the Medicare contractors address 
listed on the MSN. You can also send any additional information 
you may have about your appeal. 

5. You must file the appeal within 120 days of the date you get the 
MSN. If you want to file an appeal, make sure you read your MSN 
carefully, and follow the instructions. 

If you have Original Medicare or are in a Medicare Advantage Plan, you 
can also file a fast appeal in some cases. See page 88. 

Find Out If Medicare or Your Plan Was Billed for the Services You Got 

You can find out what was billed in one of the following ways: 

■ Ask your health care provider or supplier for an itemized statement. 
They should give this to you within 30 days. 

■ Check with your health care provider or supplier to see if they 
submitted the bill to Medicare or your plan. 

■ Check your MSN if you have Original Medicare to see if the service was 
billed to Medicare. If you are in a Medicare Advantage Plan, check with 
your plan. 

■ View your Medicare claims by visiting www.MyMedicare.gov. You can 
also call 1-800-MEDICARE (1-800-633-4227). TTY users should call 
1-877-486-2048. 



88 Section 4 — Protecting Yourself and Medicare 

Your Right to a Fast Appeal in Original 
Medicare and a Medicare Advantage Plan 

If you are getting Medicare services from a hospital, skilled 
nursing facility, home health agency, comprehensive outpatient 
rehabilitation facility, or hospice, and you think your Medicare- 
covered services are ending too soon, you may have the right to 
a fast appeal (also called an "expedited review" or an "immediate 
appeal"). Your provider will give you a notice that will tell you how 
to ask for a fast appeal. If you don't get this notice, ask for one. If 
you ask for this fast appeal, an independent reviewer will decide if 
your services should continue. 

■ Ask your doctor for any information that may help your case if 
you decide to file a fast appeal. 

■ Contact your State Health Insurance Assistance Program 
(SHIP) if you need help filing an appeal. See pages 111-114 
for the telephone number. You can also call your local Quality 

Blue words Improvement Organization (QIO). Call 1-800-MEDICARE 

in the text ( 1 -800-633-4227) to get their telephone number. TTY users 

are defined should call 1 -877-486-2048. You can also visit www.medicare.gov. 

on pages ■ If you miss the timeframe for filing a fast appeal, find out if you 

115-118. have other appeal rights: 

— If you have Original Medicare, call your local Quality 
Improvement Organization (QIO). 

— If you are in a Medicare Advantage Plan (like an HMO or 
PPO), call your plan. Look in your plan materials to get the 
telephone number. 



Section 4 — Protecting Yourself and Medicare 89 

What Is an Advance Beneficiary Notice (ABN)? 

If you have Original Medicare, your health care provider or 
supplier may give you a notice called an "Advance Beneficiary 
Notice" (ABN). 

■ This notice says Medicare probably (or certainly) won't pay for 
some services in certain situations. 

■ You will be asked to choose whether to get the items or services 
listed on the ABN. 

■ If you choose to get the items or services listed on the ABN, you 
will have to pay if Medicare doesn't. 

■ You will be asked to sign the ABN to say that you have read and 
understood the notice. 

■ An ABN isn't an official denial of coverage by Medicare. You 
could choose to get the items listed on the ABN and still ask your 
health care provider or supplier to submit the bill to Medicare or 
another insurer. If payment is denied, you can still file an appeal. 

■ You can ask the company that handles bills for Medicare for a 
prior determination of coverage to find out if Medicare will cover 
the item or service in your situation. This information is only 
available for a limited number of services and items. 

■ You may also get an ABN for other reasons, such as when your 
doctor reduces your home health care. 

If you are in a Medicare Advantage Plan (like an HMO or PPO) 
or Medicare Prescription Drug Plan, call your plan to find out if a 
service or item will be covered. 

For more information about ABNs, visit 

www.medicare.gov/Publications/Pubs/pdf/101 12.pdf to view the 
booklet "Your Medicare Rights and Protections." You can also 
call 1-800-MEDICARE (1-800-633-4227). TTY users should call 
1-877-486-2048. 



90 Section 4 — Protecting Yourself and Medicare 

Can You Appeal Your Medicare Drug Plan's 
Decisions? 

If you have Medicare prescription drug coverage (Part D), you have 
the right to do all of the following (even if you haven't bought a 
particular drug): 

■ Get a written explanation (called a "coverage determination") from 
your Medicare drug plan. A coverage determination is the first 
decision made by your Medicare drug plan (not the pharmacy) 
about your drug coverage, including whether a particular drug is 
covered, whether you have met all the requirements for getting a 
requested drug, how much you're required to pay for a drug, and 
whether to make an exception to a plan rule when you request it. 

■ Ask your drug plan for an exception if you or your doctor believes 
you need a drug that isn't on your drug plan's list of covered drugs. 

■ Ask for an exception if you or your doctor believes that a coverage 
rule (such as prior authorization) should be waived. 

■ Ask for an exception if you think you should pay less for a 
non-preferred drug because you or your doctor believes you can't 
take any of the preferred drugs for the same condition. 

You or your doctor must contact your plan to ask for a coverage 
determination or an exception. If your network pharmacy can't fill 
a prescription as written, the pharmacist will show you a notice that 
explains how to contact your Medicare drug plan so you can make 
your request. If the pharmacist doesn't show you this notice, ask to 
see it. 

A standard request for a coverage determination or exception must 
be made in writing unless your plan accepts requests by phone. You 
or your doctor can call or write your plan for an expedited (fast) 
request. Your request will be expedited if your plan determines, or 
your doctor tells your plan, that your life or health may be at risk 
by waiting. If you are requesting an exception, your prescribing 
doctor must provide a statement explaining the medical reason 
why similar drugs covered by your plan won't work or may be 
harmful to you. 



Section 4 — Protecting Yourself and Medicare 



91 



Can You Appeal Your Medicare Drug Plan's 
Decisions? (continued) 

Once your Medicare drug plan gets your request for a coverage 
determination or your doctor's statement, the Medicare drug plan has 
72 hours (for a standard request) or 24 hours (for an expedited request) 
to notify you of its decision. If the drug plan doesn't give you a prompt 
decision, and you can show that the delay would affect your health, the 
plans failure to act is considered to be a coverage determination. 

If you disagree with your Medicare drug plan's coverage determination or 
exception decision, you have the right to appeal the decision. There are five 
levels of appeals available to you. The first level is appealing through your 
plan. 

If You Want to Appeal Your Drug Plan's Coverage 
Determination Decision 

■ You have 60 days from the date of the drug plan's decision to request an 
appeal. 

■ A standard request must be made in writing, unless your Medicare drug 
plan accepts requests by phone. 

■ You or your doctor can call or write your plan for an expedited request. 

■ The Medicare drug plan has 7 days (for a standard request) or 72 hours 
(for an expedited request) from the date it gets your request to notify you 
of its decision. You may have additional appeal rights if you don't agree 
with the plan's decision. 

■ You can get help filing an appeal from your State Health Insurance 
Assistance Program (SHIP). See pages 111-114 for the telephone number. 

Blue words If your plan doesn't respond to your request for a coverage determination, 

in the text an exce pti° n > or an appeal, you can file a complaint. Call your plan 

are defined or 1-800-MEDICARE (1-800-633-4227). TTY users should call 

on pages 1-877-486-2048. 

115-118. After you appeal through your plan, you will get a notice explaining the 

next level of appeal. If you disagree with the plan's decision, you can ask for 
an independent review of your case. 

For more information about your rights and the different levels of appeals, 
visit www.medicare.gov/Publications/Pubs/pdf/101 12.pdf to view the 
booklet "Your Medicare Rights and Protections." You can also call 
1-800-MEDICARE. 



92 



Section 4 — Protecting Yourself and Medicare 

How Medicare Uses Your Personal Information 

You have the right to have your personal and health information kept 
private. The next two pages describe how your information may be 
used and given out and explain how you can get this information. 



Notice of Privacy Practices for Original Medicare 

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU 

MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS 

INFORMATION. PLEASE REVIEW IT CAREFULLY. 

By law, Medicare is required to protect the privacy of your personal medical information. 
Medicare is also required to give you this notice to tell you how Medicare may use and give 
out ("disclose") your personal medical information held by Medicare. 

Medicare must use and give out your personal medical information to provide information 
to the following: 

■ To you or someone who has the legal right to act for you (your personal representative) 

■ To the Secretary of the Department of Health and Human Services, if necessary, to make 
sure your privacy is protected 

■ Where required by law 

Medicare has the right to use and give out your personal medical information to pay for 
your health care and to operate the Medicare Program. Examples include the following: 

■ Companies that pay bills for Medicare use your personal medical information to pay or 
deny your claims, to collect your premiums, to share your benefit payment with your 
other insurer(s), or to prepare your Medicare Summary Notice. 

■ Medicare may use your personal medical information to make sure you and other people 
with Medicare get quality health care, to provide customer service to you, to resolve any 
complaints you have, or to contact you about research studies. 

Medicare may use or give out your personal medical information for the following 
purposes under limited circumstances: 

■ To State and other Federal agencies that have the legal right to receive Medicare data 
(such as to make sure Medicare is making proper payments and to assist Federal/State 
Medicaid programs) 

■ For public health activities (such as reporting disease outbreaks) 

■ For government health care oversight activities (such as fraud and abuse investigations) 

■ For judicial and administrative proceedings (such as in response to a court order) 

■ For law enforcement purposes (such as providing limited information to locate a missing 
person) 

■ For research studies, including surveys, that meet all privacy law requirements (such as 
research related to the prevention of disease or disability) 

■ To avoid a serious and imminent threat to health or safety 

■ To contact you about new or changed coverage under Medicare 

■ To create a collection of information that can no longer be traced back to you 






Section 4 — Protecting Yourself and Medicare 

How Medicare Uses Your Personal Information 
(continued) 



By law, Medicare must have your written permission (an "authorization") to use or give out 
your personal medical information for any purpose that isn't set out in this notice. You may 
take back ("revoke") your written permission at any time, except to the extent that Medicare 
has already acted based on your permission. 

By law, you have the right to take these actions: 

■ See and get a copy of your personal medical information held by Medicare. 

■ Have your personal medical information amended if you believe that it is wrong or if 
information is missing, and Medicare agrees. If Medicare disagrees, you may have a 
statement of your disagreement added to your personal medical information. 

■ Get a listing of those getting your personal medical information from Medicare. The 
listing won't cover your personal medical information that was given to you or your 
personal representative, that was given out to pay for your health care or for Medicare 
operations, or that was given out for law enforcement purposes. 

■ Ask Medicare to communicate with you in a different manner or at a different place (for 
example, by sending materials to a P.O. Box instead of your home address). 

■ Ask Medicare to limit how your personal medical information is used and given out to 
pay your claims and run the Medicare Program. Please note that Medicare may not be 
able to agree to your request. 

■ Get a separate paper copy of this notice. 

Visit www.medicare.gov for more information on the following: 

■ Exercising your rights set out in this notice. 

■ Filing a complaint, if you believe Original Medicare has violated these privacy rights. 
Filing a complaint won't affect your coverage under Medicare. 

You can also call 1-800-MEDICARE (1-800-633-4227) to get this information. Ask to speak 
to a customer service representative about Medicare's privacy notice. TTY users should call 
1-877-486-2048. 

You may file a complaint with the Secretary of the Department of Health and Human 
Services. Call the Office for Civil Rights at 1-800-368-1019. TTY users should call 
1-800-537-7697. You can also visit www.hhs.gov/ocr/hipaa. 

By law, Medicare is required to follow the terms in this privacy notice. Medicare has 
the right to change the way your personal medical information is used and given out. If 
Medicare makes any changes to the way your personal medical information is used and 
given out, you will get a new notice by mail within 60 days of the change. 

The Notice of Privacy Practices for Original Medicare became effective April 14, 2003. 



93 



94 Section 4 — Protecting Yourself and Medicare 

Protect Yourself from Fraud and Identity Theft 

Identity theft is a serious crime. Identity theft happens when 
someone uses your personal information without your consent 
to commit fraud or other crimes. Personal information includes 
things like your name and your Social Security, Medicare, or credit 
card numbers. Don't be a victim of identity theft. Guard against 
identity theft by taking action to protect yourself. 

Keep your personal information safe. You have control over when 
you provide and who you allow to have your personal information. 

Generally, no one should call you or come to your home uninvited 
selling Medicare products. Don't give your personal information 
to someone who does this. Only give personal information to 
doctors, other providers, and plans approved by Medicare, and 
to people in the community who work with Medicare, like your 
State Health Insurance Assistance Program (SHIP) or Social 
Security. Call 1-800-MEDICARE (1-800-633-4227) if you aren't 
sure if a provider is approved by Medicare. TTY users should call 
0n . Pd9 " 1-877-486-2048. 



Blue words 
in the text 
are defined 



115-118. 



Medicare plans can't ask you for credit card or banking information 
over the telephone, unless you are already a member of that plan. In 
most cases, Medicare plans can't call you to enroll in a plan; instead, 
you must call them. Call 1-800-MEDICARE to report any plans 
that ask for your personal information over the telephone or that 
call to enroll you in a plan. 

Note: Medicare demonstrations or pilot programs are allowed 
to call you to see if you want to enroll. See page 62 for more 
information about demonstrations and pilot programs. 



o 



Section 4 — Protecting Yourself and Medicare 95 

Protect Yourself from Fraud and Identity Theft 
(continued) 

If you think someone is using your personal information, you 
can call any of these numbers: 

■ 1-800-MEDICARE (1-800-633-4227). TTY users should call 
1-877-486-2048. 

■ The Fraud Hotline of the HHS Office of Inspector General at 
1-800-HHS-TIPS (1-800-447-8477). TTY users should call 
1-800-377-4950. You can also send an email to 
HHSTips@oig.hhs.gov. 

■ The Federal Trade Commissions ID Theft Hotline at 
1-877-438-4338 to make a report. TTY users should call 
1-866-653-4261. For more information about identity theft, 
visit www.consumer.gov/idtheft. 

The SMP (Senior Medicare Patrol) Program Can Help You 

The SMP Program educates and empowers people with Medicare 
to take an active role in detecting and preventing health care fraud 
and abuse. There is a SMP Program in every state, the District of 
Columbia, Guam, U.S. Virgin Islands, and Puerto Rico. For more 
information or to find your local SMP Program, visit 
www.smpresource.org. 



96 



Section 4 — Protecting Yourself and Medicare 




Blue words 



in the text 
are defined 
on pages 
115-118. 



© 



Protect Yourself and Medicare from Billing Fraud 

Most doctors, pharmacists, plans, and other health care providers 
who work with Medicare are honest. Unfortunately, there may be 
some who are dishonest. Medicare is working with other government 
agencies to protect you and Medicare. Medicare fraud happens when 
Medicare is billed for services or supplies you never got. Medicare 
fraud costs Medicare a lot of money each year. You pay for it with 
higher premiums. 

The following are examples of possible Medicare fraud: 

■ A health care provider bills Medicare for services you never got. 

■ A supplier bills Medicare for equipment different than what they 
provided to you. 

■ Someone uses another person's Medicare card to get medical care, 
supplies, or equipment. 

■ Someone bills Medicare for home medical equipment after it has 
been returned. 

■ A company offers a Medicare drug plan that hasn't been approved 
by Medicare. 

■ A company uses false information to mislead you into joining a 
Medicare plan. 

If you believe a Medicare plan or provider has misled you, call 
1-800-MEDICARE (1-800-633-4227). TTY users should call 
1-877-486-2048. 

When you get health care services, you may want to save the receipts 
you get from providers. Use your receipts to check for mistakes on 
statements you get. These include the Medicare Summary Notice 
if you have Original Medicare, or similar statements that list the 
services you got or prescriptions you filled. 

If you suspect billing fraud, here's what you can do: 

1. Contact your health care provider to be sure the bill is correct. 

2. Call 1-800-MEDICARE. 

3. Call the Inspector General's hotline at 1-800-HHS-TIPS 
(1-800-447-8477). TTY users should call 1-800-377-4950. 
You can also send an email to HHSTips@oig.hhs.gov. 



Q 



Section 4 — Protecting Yourself and Medicare 



Fighting Fraud Can Pay 

You may get a reward of up to $1,000 if you meet all these conditions: 

■ You report suspected Medicare fraud. 

■ The Inspector General's Office reviews your suspicion. 

■ The suspected fraud you report isn't already being investigated. 

■ Your report leads directly to the recovery of at least $100 of 
Medicare money. 

For more information, call 1-800-MEDICARE (1-800-633-4227). 
TTY users should call 1-877-486-2048. 

Note: For your protection, your full Medicare number is no 
longer printed on your Medicare Summary Notice. The first 5 
digits of your number are replaced with "Xs." 

How Medicare Protects You 

Medicare works with other government agencies to protect Medicare 
from fraud and to protect you from identity theft. With help from 
honest health care providers, suppliers, law enforcement, and 
citizens like you, Medicare is improving its ability to prevent fraud 
and identity theft. Some dishonest health care providers have been 
removed from Medicare, and some have gone to jail. These actions 
are saving money for taxpayers and protecting Medicare for the 
future. Below and on the next page are other ways Medicare is 
working to protect you. 

You Are Protected from Discrimination 

Every company or agency that works with Medicare must obey 
the law You can't be treated differently because of your race, color, 
national origin, disability, age, religion, or sex. If you think that 
you haven't been treated fairly for any of these reasons, call the 
Department of Health and Human Services, Office for Civil Rights 
for your state, or call toll-free 1-800-368-1019. TTY users should 
call 1-800-537-7697. You can also visit www.hhs.gov/ocr for more 
information. 



97 



98 Section 4 — Protecting Yourself and Medicare 

The Medicare Beneficiary Ombudsman 

An "ombudsman" is a person who reviews issues and helps to resolve 
them. The Medicare Beneficiary Ombudsman shares information 
with the Secretary of Health and Human Services, Congress, and 
other organizations about what works well and what doesn't work 
well in Medicare. The Ombudsman helps improve the quality of the 
services and care you get from Medicare by reporting problems and 
making recommendations. 

How Does the Medicare Beneficiary Ombudsman Help You? 

The Ombudsman makes sure information is available to all people 
with Medicare about the following: 

■ Your Medicare coverage 

■ Information to help you make good health care decisions 

■ Your Medicare rights and protections 

■ How you can get issues resolved 

Blue words The Ombudsman reviews the concerns you raise through 

in the text 1-800-MEDICARE (1-800-633-4227) and through your State 

are defined Health Insurance Assistance Program (SHIP). TTY users should 

on pages call 1 -877-486-2048. For more information about the Medicare 

115-118. Beneficiary Ombudsman, visit www.medicare.gov and select, 

"Ombudsman." 




© 



This section gives you information to help you plan ahead to 
make important health care choices. Your family, friends, and 
partners in your community may be an important part of helping 
you manage and plan for your future health care. Whether it's 
helping you compare plans or keeping a copy of your advance 
directives, be sure to ask for any help you may need from people 
you trust. 

Section 5 includes information about the following: 

Learn How to Compare the Quality of Plans and Providers . 100 

Learn About Electronic and Personal Health Records .... 101 

Plan for Long-Term Care 102-104 

Have Your Voice Heard Through Advance Directives 

(like a living will) 105-106 

If you have a question or complaint about the quality of a 
Medicare- covered service, call your local Quality Improvement 
Organization (QIO). Call 1-800-MEDICARE (1-800-633-4227) 
to get your QIO's telephone number. TTY users should call 
1-877-486-2048. You can also visit www.medicare.gov. 



100 



Section 5 — Planning Ahead 




Learn How to Compare the Quality of Plans 
and Providers 

You can't always plan ahead when you need health care, but when 
you can, take time to compare. Medicare collects information about 
the quality of care and services given by most Medicare plans and 
other health care providers and information about how satisfied 
people are with the care and services they get. 

Now you can compare the quality of care and services given 
by health and prescription drug plans, or health care providers 
nationwide by visiting www.medicare.gov or by calling your State 
Health Insurance Assistance Program (SHIP). See pages 111-114 for 
the telephone number. 

When you, a family member, friend, or SHIP counselor 
visit Medicare's website, select one of the following: 

■ "Compare Health Plans and Medigap Policies" 

■ "Compare Medicare Prescription Drug Plans" 

■ "Compare Dialysis Facilities" 

■ "Compare Home Health Agencies" 

■ "Compare Hospitals" 

■ "Compare Nursing Homes" 

These search tools on www.medicare.gov give you a "snapshot" of the 
quality of care and services these plans and providers give. Find out 
more about the quality of care and services by doing the following: 

■ Ask what your plan or provider does to ensure and improve quality 
of care and services. Every plan and health care provider should 
have someone you can talk to about quality. 

■ Ask your doctor what he or she thinks about the quality of care or 
services the plan or other health care provider gives. Talk to your 
doctor about Medicare's information about the quality of plans and 
providers. 



Section 5 — Planning Ahead 



101 




Learn About Electronic and Personal Health Records 

One way to take an active role in your health is to learn about the new 
technology that may be used to handle your health records. Two types 
of health records that are stored electronically are 1 ) Electronic Health 
Records which are records that your doctor, your doctor's staff, or a 
hospital keeps with information about your health and medical treatment 
(like lab reports), primarily for your doctor s or your hospital's use and 
2) Personal Health Records which are records you keep or control with 
health information you want to keep track of. 

Electronic Health Records 

Many health care providers, like doctors, nurses, hospitals, and equipment 
suppliers are starting to keep your information in a computer instead 
of writing the information in a paper chart. These computer records are 
called Electronic Health Records (EHRs). 

Medicare supports doctors and hospitals using this technology. 
Over time, EHRs will help your providers have the same 
knowledge about your conditions, treatments, tests, and 
prescriptions, which lowers the chances of medical errors and 
can help improve your overall quality of care. 

The Federal and state governments already have strict rules 
about protecting the privacy and security of electronic 
information. More work is being done to make sure that this 
new technology will be even more secure. You have a right to 
see and get a copy of your medical records, even when your 
information is in an EHR. 

Personal Health Records 

Personal Health Records (PHRs) are electronic records of your health 
information that you create and control. You can keep track of your 
health information, like the date of your last physical and test results, 
major illnesses, allergies, or a list of your medicines online. PHRs help 
you stay involved with your health care services. Sometimes health plans, 
health care providers, or private companies offer ways for you to create 
and keep PHRs. 

If you decide not to keep track of your health information online with a 
PHR, you should still try to keep your information in one place. 

Visit www.medicare.gov for more information on EHRs and PHRs. 



1 02 Section 5 — Planning Ahead 

Plan for Long-Term Care 

What is Long-Term Care? 

Long-term care is a variety of services including medical and 
non-medical care for people who have a chronic illness or disability. 
Long-term care can be provided at home, in the community, 
in assisted living, or in a nursing home. Most long-term care is 
non- skilled personal care assistance, such as help with everyday 
activities like dressing, bathing, and using the bathroom. 

Does Medicare pay for long-term care? 
Medicare and most health insurance plans, including Medigap 
(Medicare Supplement Insurance) policies don't pay for this 
type of care, called "custodial care." Medicare only pays for 
medically-necessary skilled nursing facility or home health care if 
you meet certain conditions. See page 20. 
Blue words 

in the text How can y° u P a y ^ or long-term care? 

are defined Long-Term Care Insurance — This type of private insurance policy 

on pages can help P a y for many types of long-term care, including both 

115-118. skilled and non-skilled (custodial) care. Long-term care insurance 

can vary widely. Some policies may cover only nursing home care. 
Others may include coverage for a range of services like adult day 
care, assisted living, medical equipment, and informal home care. 

Note: Long-term care insurance doesn't replace your Medicare 
coverage. 

Your current or former employer or union may offer long-term care 
insurance. Current and retired Federal employees, active and retired 
members of the uniformed services, and their qualified relatives can 
apply for coverage under the Federal Long-Term Care Insurance 
Program. If you have questions, visit www.opm.gov/insure/ltc or call 
the Office of Personnel Management at 1-888-767-6738. TTY users 
should call 1-800-878-5707. 

Personal Resources — You can use your savings to pay for long-term 
care. Some insurance companies let you use your life insurance 
policy to pay for long-term care. Ask your insurance agent how this 
works. 




Section 5 — Planning Ahead 

Plan for Long-Term Care (continued) 

How can you pay for long-term care? (continued) 

Medicaid— Medicaid is a joint Federal and state program that 
pays for certain health services for people with limited income 
and resources. If you qualify, you may be able to get help to pay for 
nursing home care, or other health care costs. See page 82 for more 
information about Medicaid. 

Home and Community-Based Programs — If you are already 
eligible for Medicaid, (or, in some states, would be eligible for 
Medicaid coverage in a nursing home) you may be able to get 
help with the costs of services that help you stay in your home 
instead of going to a nursing home. Examples include homemaker 
services, personal care, and respite care. For more information, 
visit www.eldercare.gov. You can also call the Eldercare Locator at 
1-800-677-1116 (weekdays 9:00 a.m. to 8:00 p.m. Eastern time) for 
your local Area Agency on Aging telephone number. 

Programs of All-Inclusive Care for the Elderly (PACE) — PACE 
is a Medicare and Medicaid program that allows people who 
otherwise need nursing home-level of care to remain in the 
community. PACE was created as a way to provide you, your family, 
caregivers, and professional health care providers flexibility to 
meet your health care needs and to help you continue living in the 
community. 

PACE provides all the care and services covered by 
Medicare and Medicaid, as authorized by a team of health 
professionals, as well as additional medically-necessary 
care and services not covered by Medicare and Medicaid. 
PACE provides coverage for prescription drugs, doctor 
care, transportation, home care, check-ups, hospital visits, 
and even nursing home stays whenever necessary. 



103 



104 



Section 5 — Planning Ahead 







Blue words 
in the text 
are defined 
on pages 
115-118. 



Plan for Long-Term Care (continued) 

How can you pay for long-term care? (continued) 
Programs of All-inclusive Care for the Elderly (PACE) 
(continued) 

With PACE, your inability to pay will never keep you from getting 
the care you need. If you have Medicare, all Medicare-covered 
services are paid by Medicare. If you have Medicare and Medicaid, 
you will either have a small monthly payment or pay nothing for 
the long-term care portion of the PACE benefit. If you don't have 
Medicaid, you will be charged a monthly premium to cover the 
long-term care portion of the PACE benefit and a premium for 
Medicare Part D drugs. However, with PACE, there is never a 
deductible or copayment for any drug, service, or care approved by 
the PACE team of health professionals. 

Long-Term Care Resources 

Use the following resources to get more information about 
long-term care: 

■ Visit www.medicare.gov and select, "Plan for Your Long-Term 
Care Needs." 

■ Call 1-800-MEDICARE (1-800-633-4227). TTY users should call 
1-877-486-2048. 

■ Visit www.longtermcare.gov to learn more about planning for 
long-term care and to get a free copy of the Own Your Future 
Planning Kit. 

■ Call your State Insurance Department to get information about 
long-term care insurance. Call 1-800-MEDICARE to get the 
telephone number. 

■ Call the National Association of Insurance Commissioners at 
1-866-470-6242 to get a copy of "A Shoppers Guide to Long-Term 
Care Insurance." 

■ Visit the Eldercare Locator at www.eldercare.gov to find your local 
Aging and Disability Resource Center. 



Section 5 — Planning Ahead 



105 




Have Your Voice Heard Through Advance Directives 

Advance directives are legal documents that allow you to put in writing 
what kind of health care you would want if you were too ill to speak for 
yourself. Advance directives most often include the following: 

■ A living will 

■ A health care proxy (durable power of attorney) 

■ After- death wishes 

Talking to your family, friends, and health care providers about your 
wishes is important, but these legal documents ensure your wishes are 
followed. It's better to think about these important decisions before you 
are ill or a crisis strikes. 

A living will states which medical treatment you would accept or refuse 
if your life is threatened. Dialysis for kidney failure, a breathing machine 
if you can't breath on your own, CPR (cardiopulmonary resuscitation) if 
your heart and breathing stop, or tube feeding if you can no longer eat are 
examples of medical treatment you can choose to accept or refuse. 

A health care proxy (sometimes called a durable power of 
attorney for health care) is another way to make sure your 
voice is heard. You use it to name the person you wish to 
make health care decisions for you if you aren't able to make 
them yourself. Having a health care proxy is important 
because if you suddenly aren't able to make your own health 
care decisions, someone you trust will be able to make these 
decisions for you. 

Advance directives can also include after- death wishes such as organ and 
tissue donation. 

If you already have advance directives, take time now to review them to 
be sure you are still satisfied with your decisions and your health care 
proxy is still willing and able to carry out your plans. Find out how to 
cancel or update them in your state if they no longer reflect your wishes. 
Make sure to give your new advance directives to your doctors, proxy, 
and family members. 

Each state has its own laws for creating advance directives. For more 
information, contact your health care provider, an attorney, your local 
office on aging, or your state health department. 



106 



Section 5 — Planning Ahead 




Have Your Voice Heard Through Advance 
Directives (continued) 

Tips 

1. Keep your original advance directives where it's easily found. 

2. Give the person you've named as your health care proxy, and 
other concerned family members or friends, a copy of your 
advance directives. 

3. Give your doctor a copy of your advance directives for your 
medical record. Provide a copy to any hospital or nursing home 
you stay in. 

4. Carry a card in your wallet that states you have advance 
directives. 




Medicare has free information sources to help you with your 
Medicare and related questions. 

Section 6 includes information about the following: 

1-800-MEDICARE 108 

www.MyMedicare.gov (for your personal 
Medicare information) 109 

www.medicare.gov (for general information) 109 

Medicare Publications 110 



108 



Section 6 — For More Information 



1-800-MEDICARE (1-800-633-4227) 
TTY Users Should Call 1-877-486-2048. 

Get Information 24 Hours a Day, Including Weekends. 

■ Speak clearly, and have your Medicare card in front of you. 
You'll be asked for your Medicare number. 

■ Say "agent" at any time to talk to a customer service 
representative, or use this chart. 



If you are calling about... Say ... 


Medicare prescription drug coverage 


"Drug Coverage" 


Claim or billing issues, or appeals 


"Claims" or "Billing" 


Preventive services 


"Preventive Services" 


"Extra help" paying health or prescription 
drug costs 


"Limited Income" 


Forms or Handbooks 


"Publications" 


Telephone numbers for your State 
Medical Assistance (Medicaid) office 


"Medicaid" 


Outpatient doctor s care 


"Doctor Service" 


Hospital visit or emergency room care 


"Hospital Stay" 


Equipment or supplies like oxygen, 
wheelchairs, walkers, or diabetic supplies 


"Medical Supplies" 


Information about your Part B deductible 


"Deductible" 


Nursing Home Services 


"Nursing Home" 



o 



People who get benefits from the RRB should call 1-800-833-4455 
with questions about Part B services and bills. 

Note: If you want Medicare to give your personal health 
information to someone other than you, you need to let 
Medicare know in writing. You can fill out a "Medicare 
Authorization to Disclose Personal Health Information" form. 
You can do this by visiting www.medicare.gov or by calling 
1-800-MEDICARE to get a copy of the form. 



Section 6 — For More Information 1 09 

Get the Information You Need Online 

Need Personalized Information? 

Register at www.MyMedicare.gov, Medicare's secure online service 

for accessing your personal Medicare information 

■ Complete your Initial Enrollment Questionnaire. 

■ Track your health care claims. 

■ Check your Part B deductible status. 

■ View your eligibility information. 

■ Track the preventive services you can get. 

■ Find your Medicare health or prescription drug plan, or search for a 
new one. 

■ Keep your Medicare information in one convenient place. 

■ Sign up to get your "Medicare & You" handbook electronically 
(see page 122). 




"Using www.MyMedicare.gov is easy! 

I keep up with my Medicare claims, 

get copies of my Medicare Summary Notices, 

and track which Medicare-covered 

preventive services I can get." 



Need General Information about Medicare? 
Visit www.medicare.gov 

■ See what Medicare health and prescription drug plans are in your 
area. 

■ Find doctors and suppliers who participate in Medicare. 

■ See what Medicare covers, including preventive services. 

■ Get Medicare appeals information and forms. 

■ Get information about the quality of care provided by nursing 
homes, hospitals, home health agencies, plans, and dialysis facilities. 

■ Look up helpful telephone numbers for your area. 

■ View Medicare publications. 

If you don't have a computer, your local library or senior center may 
be able to help you look at this information. You can also call your 
State Health Insurance Assistance Program (SHIP). See pages 111-114 
for the telephone number. 



110 



Section 6 — For More Information 



Blue words 
in the text 
are defined 
on pages 
115-118. 



Medicare Publications 

To read, print, or download copies of booklets, brochures, or fact 
sheets on the topics listed below or to see what's available, visit 
www.medicare.gov and select, "Find a Medicare Publication." You 
can search by keyword (such as "rights" or "mental health"), or 
select "View All Medicare Publications." 

If the publication you want has a check box after "Order 
Publication," you can have a printed copy mailed to you. You 
can also call 1-800-MEDICARE (1-800-633-4227), and say 
"Publications" to find out if a printed copy can be mailed to you. 
TTY users should call 1-877-486-2048. 

Search for free booklets on Medicare topics like the following: 



Preventive services 
Hospice care 
Home health care 
Medicare prescription drug 
coverage, including "extra 
help" 

Medicare Advantage Plans 
including Medicare MSAs 
and Medicare Private 
Fee-for-Service Plans 
Choosing a nursing home 



Hospital quality 

Comparing plans and health 

care providers 

Mental health care 

Kidney dialysis and transplant 

services 

Skilled nursing facility care 

Fighting fraud 

Rights and protections 

Coverage outside the U.S. 



Section 6 — For More Information 



111 



State Health Insurance Assistance Program (SHIP): 

For help with questions about appeals, buying other insurance, choosing a 
health plan, buying a Medigap policy, and Medicare rights and protections. 



Alabama 

State Health Insurance Assistance 
Program (SHIP) 
1-800-243-5463 

Alaska 

Alaska State Health Insurance 
Assistance Program (SHIP) 
1-800-478-6065 

Arizona 

Arizona State Health Insurance 
Assistance Program 
1-800-432-4040 

Arkansas 

Seniors Health Insurance 
Information Program (SHIP) 
1-800-224-6330 

California 

Health Insurance Counseling and 
Advocacy Program (HICAP) of 
California (SHIP) 
1-800-434-0222 

Colorado 

Senior Health Insurance 
Assistance Program (SHIP) 
1-888-696-7213 

Connecticut 

CHOICES 
1-800-994-9422 



Delaware 

ELDERinfo 
1-800-336-9500 

Florida 

Serving Health Insurance Needs 
of Elders (SHINE) 
1-800-963-5337 

Georgia 

GeorgiaCares 
1-800-669-8387 

Guam 

Guam Medicare Assistance 
Program (GUAM MAP) 
1-671-735-7388 
or 1-671-735-7390 

Hawaii 

SagePLUS 
1-888-875-9229 

Idaho 

Senior Health Insurance Benefits 
Advisors (SHIBA) 
1-800-247-4422 

Illinois 

Senior Health Insurance Program 

(SHIP) 

1-800-548-9034 



112 



Section 6 — For More Information 



Indiana 

State Health Insurance Assistance 
Program (SHIP) 
1-800-452-4800 

Iowa 

Senior Health Insurance 
Information Program (SHIIP) 
1-800-351-4664 

Kansas 

Senior Health Insurance 
Counseling for Kansas (SHICK) 
1-800-860-5260 

Kentucky 

State Health Insurance Assistance 
Program (SHIP) 

1-877-293-7447 

Louisiana 

Senior Health Insurance 
Information Program (SHIIP) 
1-800-259-5301 

Maine 

Maine State Health Insurance 
Assistance Program (SHIP) 

1-877-353-3771 

Maryland 

Senior Health Insurance 
Assistance Program (SHIP) 
1-800-243-3425 

Massachusetts 

Serving Health Information 
Needs of Elders (SHINE) 
1-800-243-4636 



Michigan 

MMAP (Medicare/Medicaid 
Assistance Program) 
1-800-803-7174 

Minnesota 

Minnesota State Health Insurance 
Assistance Program/Senior 
LinkAge Line 
1-800-333-2433 

Mississippi 

MS Insurance Counseling and 
Assistance Program (MICAP) 
1-800-948-3090 

Missouri 

CLAIM 
1-800-390-3330 

Montana 

Montana State Health Insurance 
Assistance Program (SHIP) 
1-800-551-3191 

Nebraska 

Nebraska Senior Health 
Insurance Information Program 
(SHIIP) 
1-800-234-7119 

Nevada 

State Health Insurance Advisory 
Program (SHIP) 
1-800-307-4444 

New Hampshire 

NH SHIP - ServiceLink Resource 

Center 

1-866-634-9412 



Section 6 — For More Information 



113 



New Jersey 

State Health Insurance Assistance 
Program (SHIP) 
1-800-792-8820 

New Mexico 

Benefits Counseling Program 
1-800-432-2080 

New York 

Health Insurance Information 
Counseling and Assistance 
Program (HIICAP) 
1-800-701-0501 

North Carolina 

Seniors' Health Insurance 
Information Program (SHIIP) 
1-800-443-9354 

North Dakota 

Senior Health Insurance 
Counseling (SHIC) 
1-800-247-0560 

Ohio 

Ohio Senior Health Insurance 
Information Program (OSHIIP) 
1-800-686-1578 

Oklahoma 

Senior Health Insurance 
Counseling Program (SHICP) 
1-800-763-2828 

Oregon 

Senior Health Insurance Benefits 
Assistance (SHIBA) 
1-800-722-4134 



Pennsylvania 

APPRISE 
1-800-783-7067 

Puerto Rico 

State Health Insurance Assistance 
Program (SHIP) 
1-877-725-4300 

Rhode Island 

Senior Health Insurance Program 

(SHIP) 

1-401-462-4444 

South Carolina 

(I-CARE) Insurance Counseling 
Assistance and Referrals for 
Elders 
1-800-868-9095 

South Dakota 

Senior Health Insurance 
Assistance Program (SHIP) 
1-800-536-8197 

Tennessee 

Tennessee Commission on Aging 
and Disability (SHIP) 
1-877-801-0044 

Texas 

Health Information Counseling 
and Advocacy Program (HICAP) 
1-800-252-9240 

Utah 

Senior Health Insurance 
Information Program (SHIP) 
1-800-541-7735 



114 



Section 6 — For More Information 



Vermont 

State Health Insurance Assistance 
Program (SHIP) 
1-800-642-5119 

Virgin Islands 

Virgin Islands State Health 
Insurance Assistance Program 
(VISHIP) 
1-340-772-7368 or 
1-340-714-4354 (St. Thomas) 
1-340-772-7368 (St. Croix) 

Virginia 

Virginia Insurance Counseling 
and Assistance Program (VICAP) 
1-800-552-3402 

Washington 

Statewide Health Insurance 
Benefits Advisors (SHIBA) 
Helpline 
1-800-562-6900 



Washington D.C. 

Health Insurance Counseling 
Project (HICAP) 
1-202-739-0668 

West Virginia 

West Virginia State Health 
Insurance Assistance Program 
(WV SHIP) 
1-877-987-4463 






Wisconsin 

Wisconsin SHIP (SHIP) 
1-800-242-1060 



Wyoming 

Wyoming State Health Insurance 
Information Program (WSHIIP) 
1-800-856-4398 



SECTION 7 



115 




s 



ection 7 includes definitions of words used throughout this 
handbook. 



Benefit Period — The way that Original Medicare measures your 
use of hospital and skilled nursing facility (SNF) services. A benefit 
period begins the day you go to a hospital or skilled nursing facility. 
The benefit period ends when you haven't received any inpatient 
hospital care (or skilled care in a SNF) for 60 days in a row. If you 
go into a hospital or a skilled nursing facility after one benefit 
period has ended, a new benefit period begins. 

Coinsurance— An amount you may be required to pay as your 
share of the cost for services, after you pay any deductibles. 
Coinsurance is usually a percentage (for example, 20%). 

Copayment — An amount you may be required to pay as your 
share of the cost for a medical service or supply, like a doctor's visit 
or a prescription. A copayment is usually a set amount, rather than 
a percentage. For example, you might pay $10 or $20 for a doctor's 
visit or prescription. 



116 Section 7 — Definitions 



Creditable Prescription Drug Coverage— Prescription drug 
coverage (for example, from an employer or union) that is 
expected to pay, on average, at least as much as Medicare's standard 
prescription drug coverage. People who have this kind of coverage 
when they become eligible for Medicare can generally keep that 
coverage without paying a penalty, if they decide to enroll in 
Medicare prescription drug coverage later. 

Critical Access Hospital— A small facility that provides outpatient 
services, as well as inpatient services on a limited basis, to people in 
rural areas. 

Custodial Care — Nonskilled personal care, such as help with 
activities of daily living like bathing, dressing, eating, getting in or 
out of a bed or chair, moving around, and using the bathroom. It 
may also include the kind of health -related care that most people do 
themselves, like using eye drops. In most cases, Medicare doesn't pay. 

Deductible — The amount you must pay for health care or 
prescriptions, before Original Medicare, your prescription drug plan, 
or your other insurance begins to pay. 

Extra Help — A Medicare Program to help people with limited 
income and resources pay Medicare prescription drug program 
costs, such as premiums, deductibles, and coinsurance. 

Inpatient Rehabilitation Facility— A hospital, or part of a hospital, 
that provides an intensive rehabilitation program to inpatients. 

Institution — A facility that meets Medicare's definition of a 
long-term care facility, such as a nursing facility or skilled nursing 
facility, not including assisted or adult living facilities, or residential 
homes. 

Lifetime Reserve Days— In Original Medicare, these are additional 
days that Medicare will pay for when you are in a hospital for more 
than 90 days. You have a total of 60 reserve days that can be used 
during your lifetime. For each lifetime reserve day, Medicare pays 
all covered costs except for a daily coinsurance. See page 120 for the 
amount you will pay in 2009. 



Section 7 — Definitions 



Medically Necessary — Services or supplies that are needed for 
the diagnosis or treatment of your medical condition and that meet 
accepted standards of medical practice. 

Medicare-approved Amount— In Original Medicare, this is the 
amount a doctor or supplier that accepts assignment can be paid. 
It includes what Medicare pays and any deductible, coinsurance, 
or copayment that you pay. It may be less than the actual amount a 
doctor or supplier charges. 

Premium — The periodic payment to Medicare, an insurance 
company, or a health care plan for health or prescription drug 
coverage. 

Primary Care Doctor — Your primary care doctor is the doctor you 
see first for most health problems. He or she makes sure you get 
the care you need to keep you healthy. He or she also may talk with 
other doctors and health care providers about your care and refer 
you to them. In many Medicare Advantage Plans, you must see your 
primary care doctor before you see any other health care provider. 

Quality Improvement Organization (QIO)— A group of 
practicing doctors and other health care experts paid by the Federal 
government to check and improve the care given to people with 
Medicare. 

Referral — A written order from your primary care doctor for you 
to see a specialist or get certain medical services. In many Health 
Maintenance Organizations (HMOs), you need to get a referral 
before you can get medical care from anyone except your primary 
care doctor. If you don't get a referral first, the plan may not pay for 
the services. 

Service Area — A geographic area where a health insurance plan 
accepts members if it limits membership based on where people live. 
For plans that limit which doctors and hospitals you may use, it's 
also generally the area where you can get routine (non-emergency) 
services. The plan may disenroll you if you move out of the plan's 
service area. 



117 



118 Section 7 — Definitions 



Skilled Nursing Facility (SNF) Care— This is a level of care that 
requires the daily involvement of skilled nursing or rehabilitation 
staff. Examples of skilled nursing facility care include intravenous 
injections and physical therapy The need for custodial care (such 
as help with activities of daily living, like bathing and dressing) 
can't qualify you for Medicare coverage in a skilled nursing 
facility if that's the only care you need. However, if you qualify 
for coverage based on your need for skilled nursing care or 
rehabilitation, Medicare will cover all of your care needs in the 
facility, including help with activities of daily living. 

TTY — A teletypewriter (TTY) is a communication device used 
by people who are deaf, hard-of-hearing, or have a severe speech 
impairment. People who don't have a TTY can communicate with 
a TTY user through a message relay center (MRC). An MRC has 
TTY operators available to send and interpret TTY messages. 



AWPMaVUlUPAL 




Your 2009 Monthly Premiums for Medicare 

Part A (Hospital Insurance) Monthly Premium 

Most people don't pay a Part A premium because they paid Medicare 
taxes while working. 

You pay up to $443* each month if you don't get premium-free Part A. 
Part B (Medical Insurance) Monthly Premium 



If Your Yearly Income Is 


You Pay 


File Individual Tax Return 


File Joint Tax Return 




$85,000 or below 


$170,000 or below 


$96.40* 


$85,001-$107,000 


$170,001-$214,000 


$134.90* 


$107,001-$160,000 


$214,001-$320,000 


$192.70* 


$160,001-$213,000 


$320,001-$426,000 


$250.50* 


above $213,000 


above $426,000 


$308.30* 



Note: If you get a monthly benefit payment from Social Security, the 
RRB, or the Civil Service, you must have your Part B premiums deducted 
from your monthly benefit payment. If you don't get any of these benefit 
payments and choose to sign up for Part B, you will get a bill. If you 
choose to buy Part A, you will always get a bill for your premium. You 
can mail your premium payments to the Medicare Premium Collection 
Center, P.O. Box 790355, St. Louis, MO 63179-0355. If you get a bill from 
the RRB, mail your premium payments to RRB, Medicare Premium 
Payments, P.O. Box 9024, St. Louis, MO 63197-9024. 

Part C and Part D (Medicare Health and Prescription Drug Plan) 
Monthly Premiums 

Contact the plans you're interested in for the actual plan premium. 
You also pay the Part B premium (and Part A if you don't get it 
premium-free), or an amount for your Part D coverage is added to your 
Part C premium. See page 53 to find out how to save on your Part B 
premium. 

*If you pay a late enrollment penalty, this amount is higher. 



120 



2009 Medicare Costs 



What you pay in 2009 if you have Original Medicare 

Part A Costs for Covered Services and Items 



Blood 

Home 
Health Care 


If the hospital has to buy blood for you, you must either pay the 
hospital costs for the first 3 pints of blood you get in a calendar year or 
have the blood donated. In most cases, the hospital gets blood from a 
blood bank at no charge, and you won't have to pay for it or replace it. 


You pay: 

■ $0 for home health care services 

■ 20% of the Medicare-approved amount for durable medical 
equipment 


Hospice 
Care 

Hospital 


You pay: 

■ $0 for hospice care 

■ A copayment of up to $5 per prescription for outpatient 
prescription drugs for pain and symptom management 

■ 5% of the Medicare- approved amount for inpatient respite care 
(short-term care given by another caregiver, so the usual caregiver 
can rest) 

Medicare doesn't cover room and board when you get hospice care in 
your home or another facility where you live (like a nursing home). 


You pay: 

■ $1,068 deductible and no coinsurance for days 1-60 each benefit 
period 

■ $267 per day for days 61-90 each benefit period 

■ $534 per "lifetime reserve day" after day 90 each benefit period 
(up to 60 days over your lifetime) 

■ All costs for each day after the lifetime reserve days 

■ Inpatient mental health care in a psychiatric hospital limited to 
190 days in a lifetime 

See "Medical and Other Services" on page 121 for what you pay for 
doctor services while you are a hospital inpatient. 


Stay 


Skilled 
Nursing 
Facility Stay 


You pay: 

■ $0 for the first 20 days each benefit period 

■ $133.50 per day for days 21-100 each benefit period 

■ All costs for each day after day 100 in a benefit period 



Note: All Medicare Advantage Plans must cover these services. Costs vary by plan but 
may be either higher or lower than those noted above. Check with your plan. 



2009 Medicare Costs 



121 



What you pay in 2009 if you have Original Medicare 
(continued) 

Part B Costs for Covered Services and Items 



PartB 
Deductible 

Blood 



Clinical 
Laboratory 
Services 
Home Health 
Services 

Medical and 
Other Services 



Mental Health 
Services 

Other Covered 
Services 

Outpatient 

Hospital 

Services 



You pay the first $135 yearly for Part B-covered services or 
items. 



If the provider has to buy blood for you, you must either 
pay the provider costs for the first 3 pints of blood you get 
in a calendar year or have the blood donated. In most cases, 
the provider gets blood from a blood bank at no charge, 
and you wont have to pay for it or replace it. You pay 20% 
of the Medicare-approved amount for additional pints of 
blood you get as an outpatient, and the Part B deductible 
applies. 



You pay $0 for Medicare-approved services. 



You pay $0 for Medicare-approved services. You pay 20% 
of the Medicare- approved amount for durable medical 
equipment. 



You pay 20% of the Medicare- approved amount for most 
doctor services (including most doctor services while 
you are a hospital inpatient), outpatient therapy*, most 
preventive services, and durable medical equipment. 



You pay 50% for most outpatient mental health care. 



You pay copayment or coinsurance amounts. 



You pay a coinsurance or copayment amount that varies 
by service for each individual outpatient hospital service. 
No copayment for a single service can be more than the 
amount of the Part A hospital deductible ($1,068 in 2009). 



* In 2009, there may be limits on physical therapy, occupational therapy, and 
speech-language pathology services. If so, there may be exceptions to these limits. 

Note: All Medicare Advantage Plans must cover these services. Costs vary by plan 
but may be either higher or lower than those noted above. Check with your plan. 



122 



2009 Medicare Costs 



Part C and Part D (Medicare Health and Prescription Drug 
Plans) Costs for Covered Services and Supplies 

Cost information for the Medicare plans in your area is available 
by visiting www.medicare.gov You can also contact the plan, or 
call 1-800-MEDICARE (1-800-633-4227). TTY users should caU 
1-877-486-2048. You can also call your State Health Insurance 
Assistance Program (SHIP). See pages 111-114 for the telephone 
number. Medicare Advantage Plans (like an HMO or PPO) must 
cover all Part A and Part B-covered services and supplies. Check 
your plan's materials for actual amounts. 

The figures below are used to determine the Part D late 
enrollment penalty. The national base beneficiary premium 
amount can change each year. For more information about 
estimating your penalty amount, see page 68. 

2009 



Part D National Base Beneficiary Premium 



$30.36 



1% Penalty Calculation 



$.30 



O 



Medicare cares about what you think. If you have general 
comments about this handbook, call 1-800-MEDICARE or 
email us at medicareandyou@cms.hhs.gov. We won't be able to 
respond to your comments about the handbook, but we will 
consider your feedback when writing future versions. 




Choose to Get Future Handbooks Electronically. 

Save tax dollars by signing up to access your future "Medicare 
& You" handbooks electronically (also called the eHandbook). 
Visit www.MyMedicare.gov to request the 2010 and future 
eHandbooks. We'll send you an email next October when 
the new eHandbook is available. You won't get a copy of your 
handbook in the mail if you choose to get it electronically. 



123 



Notes 






■ 



Tips To Help Prevent 
Medicare Fraud 



DOs 

DO protect your Medicare Number (on your Medicare 
card). Treat your Medicare card like it is a credit card. Don't 
ever give it out except to your doctor or other Medicare 
provider. Never give your Medicare or Medicaid number in 
exchange for free medical equipment or any other free offer. 
Dishonest providers will use your numbers to get payment 
for services they never delivered. 

DO remember that nothing is ever "free." Don't accept offers 
of money or gifts for free medical care. 

DO ask questions! You have a right to know everything 
about your medical care including the costs billed to 
Medicare. 

DO educate yourself about Medicare. Know your rights and 
know what a provider can and can't bill to Medicare. 

DO use a calendar to record all of your doctor's 
appointments and what tests or X-rays you get. Then check 
your Medicare statements carefully to make sure you got 
each service listed and that all the details are correct. 

DO be cautious of any provider or plan representative who 
says he has been approved by the Federal government. 

DO be wary of providers who tell you that the item or 
service isn't usually covered, but they "know how to bill 
Medicare" so Medicare will pay. 

DO make sure you understand how a plan works before you 
join. 






Tips To Help Prevent 
Medicare Fraud 

DO always check your pills before you leave the pharmacy 
to be sure you got the full amount. If you don't get your full 
prescription, report the problem to the pharmacist. 

DO report suspected instances of fraud. See pages 88-89 to 
find out who to call. 

DO review your Medicare payment notice for errors. The 
payment notice shows what services or supplies were billed 
to Medicare, what Medicare paid, and what you owe. Make 
sure Medicare wasn't billed for health care services or 
medical supplies and equipment you didn't get. If you spend 
time in a hospital, make sure the admission date, discharge 
date, and diagnosis on your bill are correct. 

DON'Ts 

DON'T allow anyone, except your doctor or other Medicare 
providers, to review your medical records or recommend 
services. 

DON'T contact your doctor to request a service that you 
don't need. Don't let anyone persuade you to see a doctor 
for care or services you don't need. 

DON'T accept medical supplies from a door-to-door 
salesman. If someone comes to your door claiming to be 
from Medicare or Medicaid, remember that Medicare and 
Medicaid don't send representatives to your home. 

DON'T be influenced by certain media advertising about 
your health. Many television and radio ads don't have your 
best interest at heart. 



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G*> U.S. GOVERNMENT PRINTING OFFICE : 2008-80009-199 



j OSS Library 

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i 750C Security Bivd 



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CMS LIBRARY 



U.S. DEPARTMENT OF HEALTH 
AND HUMAN SERVICES 

Centers for Medicare & Medicaid Services 
7500 Security Boulevard 
Baltimore, Maryland 21244-1850 

Official Business 

Penalty for Private Use, $300 

CMS Publication No. 10050 
September 2008 



3 60=15 DDD1DTD3 T 



National Medicare Handbook 



Also available in Spanish, Braille, Audiotape, 

Large Print (English and Spanish) 

Suspect fraud? Call the Inspector General's hotline 

at 1-800-HHS-TIPS (1-800-447-8477). TTY users 

should call 1-800-377-4950. 

New address? Call Social Security at 1-800-772-1213. 

TTY users should call 1-800-325-0778. 



¥■ 



CENTERS for MEDICARE & MEDICAID SERVICES 



www.medicare.gov 

1-800-MEDICARE (1-800-633-4227) 

TTY 1-877-486-2048 



^Necesita usted una copia de este manual en Espanol? 
Llame GRATIS al 1-800-MEDICARE (1-800-633-4227). 
Los usuarios de TTY deberan llamar al 1-877-486-2048. 



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